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r <br /> UNIFIED PROGR4'VI CONSOLIDATED FORM _ <br /> UNDERGROUND STORAGE TANK RAY 62008 <br /> CERTIFICATION OF INSTALLATION/MODIFICATIQi�T�oAQ��N co <br /> (One form per project) ENVI UN <br /> I. FACILITY INFORMATION ,CP ARTIyE <br /> Nr <br /> FACILITY ID#(Agency Use Onll% i. <br /> BUSINESS NAME(Same as Facility Alame or DBA—Doing Business As) �. <br /> BUSINESS'SITE ADDRESS ^[103• CITY 104. <br /> II. INSTALLATIO /MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aWIvl 4832. WORK AUTHORIZED UNDER PERMIT asst. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPNG INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑,4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT /C;2/ <br /> 5. <br /> S.OTHER <br /> d'DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION axza. <br /> tr 7 V <br /> CONTRACTOR LICENSE# Q 4x2" ICC CERTIFICATION# 482c. <br /> // f <br /> N. CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or if required by the local agency,inspected and certified <br /> b -a registered professional engineer having education and ex rience with underground storage tank stem installations. <br /> SIG URE OF TANK O ER OR OWNER'S AGENT DATE • PHONE 487. <br /> 1 <br /> CERTIFIER'S NA pR{ r1w, / 485. CERTIFI R'S TITLE: r :-. 486- <br /> et le di <br /> NAME OF CE FIER'S EMPLOYER(DBA) °ss' CERTIFIER'S RELATIONSHIP TO TAVK OWNER 489 <br /> ��1�� , � ��l'1-��>,c�c'+'T ���� [--] I,TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ .CONTRACTOR ❑ 4.PROPERTY OWNER <br /> 5.OTHER AUTHORJZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(IV2007)-112 www.unidoes.org <br /> a -d Zt,E9I9-GOz aUI SJ0 oeJgUoO nI agii3 eL�, :OI ZO 90 Pew <br />