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RECE,Y <br /> .-En, <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK MAY 2 3 2013 <br /> CERTIFICATION OF INSTALLATION /MODI ON <br /> I NMffNqfm r ro CCL) <br /> I. FACILITY INFORMATION Lj' R7*MENT <br /> FACILITY ID#(Agency Use Onh) 1. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Daiug Busing As) 3. <br /> 4 % 9 C.. q <br /> &14�— <br /> BUSINESS`SrrF ADDRESS I03. CITY 04. <br /> 171 64 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aooly) 413a. WORK AUTHORIZED UNDER PERMIT 483h. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> Lj 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: n4X3. <br /> p / <br /> 77)` Tri g P? 75�Alj <br /> -- 1fU 5r7�-C Gcr..�, ����r�•��� i <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> /-.7/VP ��p ,stile-. <br /> CONTRACTOR LICENSE.# 4s2n. ICC CERTIFICATION?! 482v. <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 storage tanks stem installations. <br /> SIGNATU •OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 497 <br /> 37 <br /> CERTIFIER'S AME_(print) 485 CER9 IFI R'S TITL 426. <br /> NAME OF CERTIFIER'S EAVLOYER(DBA) agg CERTIFTER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 1 TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(17/2007) <br />