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UNI D PROGRAM CONSOILJDATED FORR' <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />I. FACILITY INFORMATION <br />FACH,ITY ID # (Agency Use Only) <br />1. <br />BUSINESS NAME (Same as Facility Name or DBA — Doing Business As) 3. <br />6 0 Z705 �I-Yk <br />—6Q& <br />BUSINESS SITE ADDRESS 17crry 104. <br />-3z-c)z -y-Hom 'r COIV6, S &C k <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check dtLA"WW 483& <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />n 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />n 2.'PIPING INSTALLATION OR REPLACEMENT <br />Fl 3. UMP INSTALLATION OR REPLACEMENT <br />UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />OTHER <br />9 <br />DESCRIPTIOD(OF WORK BEING CERTI 71E 483c. <br />0141 /' <br />_Z 3 Af <br />ot-) <br />M. CONTRACTOR INFORMATION <br />N F CONTRACTOR D INSTALLATION / MODIFICATION 482a. <br />JPEO <br />! b -el -J <br />CONTRACTOR LICEN 71 <br />: SE #1(# <br />482c. <br />ICC CERTIFICATION <br />L/3q 'g?�,C <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 1)4 been incted d approved by the local agency, or if required by the local agency, inspected and certified <br />reg#ftered p#6fessionapeminzavis g education and ex rience with underground storage tank system installations. <br />OWNER WNER 0 AGENT <br />DATE 484 <br />487, <br />1PHONE <br />! 1 'S A(print) 485. <br />2�WIS <br />Z <br />CERTIFIEWS TITLE: 496. <br />L <br />-,ME <br />6e ely a -e,, <br />7-- <br />, ---c, <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488. <br />CERTMER'S RELATIONSHIP TO TANK OWNER 489. <br />A7,5156 -le <br />0 1 K OWNER ❑ 2. TANK OPERATOR <br />V3CO�NTRACTOR <br />❑ 4. PROPERTY OWNER <br />[] 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br />