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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (onJAN r o, .)' <br /> I. FACILITY INFORMATION EWRONK&MEET LTH <br /> r <br /> IT/ ER <br /> FACILITY ID#(Agency Use Only) TT <br /> 3 <br /> BUSINESS NAME(Same as FACILITY NAN Eor DBA—Doing Business As) <br /> 104. <br /> B 'S% <br /> S S TE ADDRES 103. Y <br /> 1 <br /> IL INSTALLATION!MODIFICATION PROJECT DESCRIPT N <br /> 4836. <br /> 483a WORK AUTHORIZED UNDER PERMIT <br /> TYPE OF PROJECT(Check all that apply) <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT (P y <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT `y i� <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> IR 5.OTHER 483c <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> III. CONTRACTOR INFORMATION <br /> 482& <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> 'e. 482c. <br /> CONTRACR LICE# 4826. ICC CERTIFICATION# <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 en ineer having education and ex erience with underground storage tanks stem installations. 487 <br /> GNATURE OF TAN ER OR OWNER'S AGENT <br /> DATE 484 PHONE <br /> 486. <br /> 485 CERTIFIER'S TITLE: <br /> TI R'S NAME(pri „�.... <br /> f'1 489. <br /> 488 CERTIFIER'S RELATIONSHIP TOT NK OWNER <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) <br /> 1 ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ra,�"V%fif4 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> Rev.(12/2007) <br /> UPCF UST-C-1/2 <br />