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RIFI�P= <br /> R(�LtHED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK ENVIRONMENT HEALTH <br /> CERTIFICATION OF INSTALLATION /MODIFIdiRMNERVICES <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) <br /> COUAIY y 9 tl <br /> BUSINESS SITE ADDRESS °3 CITY 1114 <br /> �?5�S ) clti�7� Y C�crB �S4LID. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 411a_ WORK AUTHORIZED UNDER PERMIT 4911, <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date). <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT Zt� <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 5 �l d <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT �} <br /> ® 5.OTHER �� 0 / <br /> DESCRIPTION OF WORK BEING CERTIFIED: 48k <br /> S i - --�? 7 PPO L)ttC T LlWr- SMA <br /> W i-04 /\1-65w' -33 6 o ZC - SLIT�3 f t"A P r SEiVSo . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> L CW Te A t, PE-TRC L e-U l" M q 1Af-7'&nV-J AI C <br /> CONTRACTOR LICENSE# 4126. ICC CERTIFICATION# 482c <br /> ��11 1L4 ,r,3i/S`�5 <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 /> SIGNATURE OF TANK OWNER PR OWNE 'S AGENT DATE., / 4x4. PHONE 4%2 <br /> CERTIFIE SN ME( riot) 4R� CERTIFIE�;S TITLE: 496 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4ss CERTIFIER'S RELATIONSHIP TO TANK OWNER 499 <br /> � ]� ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> 10�✓��Q� —CU `� R s.moCONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />