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UNIFIED PROGRAM COINSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTWICATTON OF INSTALLATION ! MODIFICATION <br />...(One foanperproject).. _ _ . <br />c. �za yF�'-�'£�*"E- ,..�, �',ff 7"P,y k'b.� w �¢ n,,,�'�d�Sj T .t �x+v� ve K ti•1+�L: ^f" �. va r � c, +R. <br />� a�.5x _,�-._::,,. .. _; e x __-e:�.�4a-a..•,}+'k".. �':._ w..: ., ,...:a_,. .-.,n._..... . �. ,t _ ..,w�si,+...+::Y ,.re � �.. <br />FACILITY ID# (Agency Use Only) <br />Cc <br />BUSIN£S, mjegsrF a N e or - Doing Btain=&) <br />BUS S ADDRESS CITY <br />TYPE OF PRO)ECT (Checi 4 that WORKAUTHORMM UNDER PERMIT 4S3b. <br />.© 1. TANK INSTALLATION OR REPLACEMEN7 (Number or Daae): <br />2. PIPING INSTALLATION OR REPLACEMENT <br />Q: 3. SUMP INSTALLATION OR REPLACEMENT qg, <br />Q 4. UNDER DISPENSERCOI,TAuz ENT INSTAL.iA'ITON OR REPLACEMENT <br />❑ 5.OTEiER �. <br />LJ Mixt.. l <br />1 <br />CONTIEACTOR Ll � � <cte ICC CERTIFICATION # 422` <br />I certify that the information,pro,7ded herein is true, accurate, and that the following conditions have been satisfied.: <br />• The installerbas met the -requirements set forth in 23 CCR §2725, subdivisions (g) and (h). <br />• The underground storage tang, any primary .piping, and any secondary containment- was installed according to applicable <br />voluntary consensus standards -and apy,manufacturer's written installation -instructions. <br />• All work listed in the manufacturer's installation hec:liist 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 'stered prqfessional engineer having- education and experience with underground storage 'System installations. <br />SIG OF TANK OR OWNER'S AGENT DA 414' <br />� a�PHONE 4s7- <br />TIFIERIS N <br />'Nfikffi OF CER 'S I <br />LI�CF UST -C Rev. (IZP-007) -12 <br />(DBA) '$B CERTIFIER'S RELATI( <br />/ .0 L TANK OWNER <br />Q 3. CoNmACTOR <br />S. OTHER AU HOF <br />vm-munidoci.org' <br />PTO. TANK OANER <br />.El' 2 TANK OPER4T0R <br />0 4. PROPERTY OWNER <br />AGENT OF TANK OWNER <br />Z'd Zt,E919t,6021 sJ04ae4UO3 AI 84113 eZS:LO OT ET 4o0 <br />