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12-09-`08 14:36 FROM-WENDT CONSTR. 1-209-547-9312 T-542 P02/02 U-662 <br /> UNIFIED PROGRAM CONSOLMATED FORM <br /> UNDERGROUND STORAGIE TANIC <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per Proles) <br /> TM _ <br /> L'FACILITY INFORMATION <br /> FACILITY IQ#(Agemy Use Only) <br /> . .I I I I TTT11- <br /> BUSINESS NAME(szm=mcu rrYNAmE ar DBA-Doing Berk.Aa) 5. <br /> 1-04i .--Dod A ki uor <br /> BUSINESS SITE ADDRESS <br /> y iw CITY ia+. <br /> ,Ix .INSTALLATION/MODIFICATION PROJECT DIESCRIPTIOIY; <br /> TYPE OF PROJECT(Check an that aoarvl aLI` woRx AUTHORIZED UNDER PERMIT 4836. <br /> i ❑ L TANK INSTALLATION OR REPLACEWNT (Number or Date): <br /> i ❑2.PIPING INSTALLATION OR REPLAMMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 9.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT � •—, <br /> 5.OTFIER. <br /> IDN OF WORK BEING CERTIFIED, aloe <br /> E f� 11, ! �ura� ISO per E*fC,k►Ve_ o v�.- uzc) <br /> 1 <br /> i <br /> i <br /> .. -III. CONTRACTOR WFORKATION, . <br /> NAME OF CONTRACTOR WHO PERFOPMIED INSTALLATION/MODIFICATION <br /> CU &tf uc�l ar <br /> CONTRACTOR LICENSE# q26' ICC CERTIFICATION 0 \/ <br /> IV.'CERTIFICATION <br /> i <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> a 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 /> voluntaty consensus standards and any manufacturer's written installation instructions. <br /> a All work listed in the manufacturers installation checklist has been completed. <br /> a The inswllatio I as been inspected and approved by the local agency,or if required by the local agency,inspected and certified <br /> b are isle rofessional engirwA having education and ex science with uridSZound storage tank system installations. <br /> 1'NAN(E <br /> IGNA O R O S AGENT DATE 494, PHONE a . <br /> - e 12 R b (.2a l )-Sr-4110 <br /> CBR 'S N NIE(ptiat) 485 CERTIFIER'S TITLE: '8a <br /> OF CERTIFIEEgR'S ENIPLOYM(DDA) 433 CERTIFTER•S RJeI.ATIONSHIP TO TANSK OWNER TOT- <br /> �" COd1 S �ft�G ❑ L TANK OWNER ❑ 2 TAMC OPERATOR <br /> CONTRACTOR ❑ a.PROPERTY OWNER <br /> I 1 ' ❑ 3.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCP'UST-C-VZ Rev.(12/21107) <br /> i <br />