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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (Ono form perproles) <br /> I. FACILITY INFORMATION <br /> FACILITY M#(Agency UW Only) 1. <br /> BUSINESS NAME(Sm=FACR=KAME ocDHA-Dome&0iwn Ai) 3_ <br /> BUSINESS SITE ADDRESS )a I CITY 104. <br /> C , r' <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Cbwk all dW snotvl ` WORK AUTHORIZED UNDER PERMIT Mh <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT C� U , 7 U�.� <br /> [j4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT c� (' <br /> S.OTHER <br /> ESCRIPTION OF WORK BEING CERTIFIED: ` <br /> /,JOd 7TOn/ ���✓�233vr' �Sc-r✓�Sv2 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4V` <br /> CONTRACTOR LICENSE#' ICC CERTIFICATION# <br /> W.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 PnmarY 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 <br /> and testified <br /> a fessionalngincer having education and ex 'once with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE " PHONE <br /> ,8& <br /> CEI"IfIAME( , CERTIFIERS TITLE: <br /> LnN Z:D`ry--' <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) M CERTIFIER'S RELATIONSHIP TO TANK OWNER uv. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> [33.CONTRACTOR [34.PROPERTY OWNER <br /> em(-�— 7 V S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-In Rev.(11rM7) <br />