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AOL <br /> U W IED PROGRAM CONSOLIDATED FOR . <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project) <br /> LFACILITY 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. CI Y 104. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483 . <br /> R�Qlarc�E ��isfi �PiP� wah ow <br /> � ouEd ��ep� axe pgpDG ! <br /> VOroJA OF-A (epVXU4 SSP XkA-fA 1CM{5 tk (bCAL i 6Pc� <br /> W.,L Pt( <br /> III. 'CONTRACTOR INFORMATION <br /> NAME OF CONTRACT O WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> CONTRACTOR 14-7 <br /> C1LICENSE# 14 4826. ICC <br /> �CERTIFICATION <br /> 7#Q 482c. <br /> l 5 1 1 ) <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 tank system installations. <br /> SIGNATURE OF TANK ER OR ER'S AGENT DATE / 484. PHONE p 487. <br /> CERT IER',S NAME print) 485. RTIFIER'S TITS 486. <br /> kn <br /> NAME OF CIEIJ.R_T.IFIER``'S��''EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> I +, 1\ evq> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> (�Jt '�A ` JSgz CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />