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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anDly) 483& WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION 4.UNDER DISPENSER CONTA N � <br /> CONTAINMENT INSTALLATION OR REPLACEMENT LACEMENT ��/ � <br /> ❑ <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> 1\E 11I� S111-AP �" t1�AqV1t�I l <br /> T- -rm fe-�" 9-6-P I PC t..)/ S':►- i <br /> (.(- wlt-k Sr-A-vC> r'7-V1 A!2 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> CONTRACTOR LICENSE# 482b' ICC CERTIFICATION# 482c, <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' manufactur ' installation checklist has been completed. <br /> • The installigrorf has been i ted and approved by the local agency,or if required by the local agency, inspected and certified <br /> b re ' red rofess' en neer having education and ex erience with underground storage tanks stem installations. <br /> F TANK O OR OWNER'S AGENT DATE 484 PHONE 487. <br /> ZL- 1 0 <br /> CE TIFIER'S NAME(print) 485' CERTIFIER'S TITLE: 486' <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />