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! r <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 /> Co�,>•.� CI,b -76 <br /> BUSINESS SITE ADDRESS 103. BUSINESS SITE CITY 104. <br /> Iib lva 4c1t:40- <br /> II. IN TALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a WORK AUTHORIZED UNDER PERMIT 4836' <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> Ej--T PIPING INSTALLATION OR REPLACEMENT <br /> [1r3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER J <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> Z��Iac���Jl PCviI e Icvs c v <br /> co <br /> p iZt:L�4C ��L51 i ASC v .i It"� tJ'tC�C 1 i> e <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# 482` <br /> -7e (3 2- <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 /> • nst lation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> re tstere sional engineer having education and ex erience with underground storage tank system installations. <br /> SI AT OF TA K O ER OWNER'S AGENT DATE 484. PHONE 487 <br /> C TIFI R'S NAME(print) 485' CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> �7 69-I.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> Y i�V N ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org Effective 01/17/08 <br />