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07 <br /> r UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> 1. FACILITY INFORMATION <br /> FACILITY ID p(Agency We Only) t <br /> BUSINESS/NgAMMEp(S�a UFACR=NA Or DBA—Doing Bu'nm As) 3 <br /> Sy� W <br /> BUSINESS SITE ADDRESS 103, CITY ID4 <br /> te`f <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoDlvl 483. WORK AUTHORIZED UNDER PERMIT 413b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ry <br /> ❑ 9( <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 1 Q <br /> F-14.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 40134 <br /> r�i�Ee.Q JOg Set�sazUell� SV(��+ . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICAIION 483. <br /> Sekuj(-e, 15 + +C60 7S4 J0-C . <br /> CONTRACTOR LICENSE 4 4126. ICC CERTIFICATION p 4g2c <br /> 48St i?4 I t 3 o s 3.-(4 - UT <br /> IV.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 /> by a registered Professional engineer having education and ex erience with underground Stora a tanks Stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> otzuu.v (i i(ty 4 ) zq-3 03q <br /> CERTIFIER'S NAME nt) 485 CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DHA) OF CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> U\_� ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> eakS <br /> S 4 �L�e . 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST•C-12 <br /> Rev.(12/1007) <br />