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0 0 <br /> a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACII.ITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t< <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. <br /> L.' !2 C 1_6 k <br /> BUSINESS SITE ADDRESS 103• CITY <br /> ®�03 CLvi3 J3�vo S roe ^l <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoalvl 483' WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.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 /> t?,'�'PLQ .�Cyte®.syn-Y �pm r -CJ nl r7 �- fA G 5 Pu�-✓3�Z, p✓ �7' ��A u c',7' <br /> INFO <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> 6? (C-?,. - N l+J <br /> CONTRACTOR LICENSE# 407 CERTIFICATION# 482a <br /> Z2® 1�3 S7-sD aqq — Ui <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 under and store a tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484, PHONE 9 487. <br /> CERTIFIER' NAME(print) 48s. CERTIFIER'S TITLE: 486- <br /> TAme6 1z�rLg ,I +N <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> �J r j 1ZYL— �l,1 W i ati ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> �3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidoes.org <br />