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UNIFIED PROGRAM CONSOLIDATED Fur—Ed <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> i. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same es FACUMY NAME or DBA-Doing Business As) <br /> -� I <br /> 1111d <br /> BUSINESS SITE ADDRESS 103. CITY <br /> 0(4,34a - (Z 1 <br /> Sia ' ' ►n <br /> II. INSTALLATION/MODIFICATION PROJECTSESCMPTION T <br /> TYPE OF PROJECT(Check all that annly) 493& WORK AUTHORIZED UNDER b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): PERMIT 48 <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT4.UNDER «� <br /> ❑ S.OTHER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT Sk o O j I ' 1 <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 403c <br /> III. CONTRACTOR]INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> J e.t u,C-ei S h v'ter imOgle <br /> S . <br /> CONTRACTOR LICENSE#1> �I pp 4G / 482b. ICC CERTIFICATION# G ® { 4B2c. <br /> '"'f' 8 � f0T e�aZ � Si ® V c <br /> IV.CER CATdON <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 engine r havin education and ex rience with under ound Stora a tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494PHONE <br /> V- 1- A A4( 87. <br /> �f ro ( ? ) 4 <br /> CERTIFIER'S NAME nnt) 465 CERTIFIER'S TITLE: 486. <br /> RAEnL! EITH A ' Q <br /> t-eV <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RLATIONSHIP TO TANK OWNER 489. <br /> ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> 1 ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />