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Apr 09:30a 2 -367-5424 p.2 <br /> UNIFIED PROGRAM CONSOLIDATED,FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One fore per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t. <br /> BUSINESS NAME(Saneas FACQSCY NA41Eor Dsa-Doing Somas As) 3' <br /> .fit„ ,J&A0J1,A) COUjOy -06AIFf-s OeC-AAcod S C`_OA)7 5k <br /> BUSINESS SITE ADDRESSe0 <br /> 3. CITY ioa. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that mMW 481L WORK AUTHORIZED UNDER PERMIT 483t. <br /> ❑ L TANK INSTALLATION OR REPLACEMENT (Number or Date}: <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT //� <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT }R DO.5' o 63 3 7 <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: SY51LCAJ. `"o <br /> V ° /000 L/�-(LV iJ�d/4 f�W f� (( 6!Y L V L) A)a-Z-4 ~�S '� !�8 ®ami 4414--"t- <br /> �r�SCS r I <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION J MODIFICATION,j,�5SS6 R UM6,�J 492L <br /> J O..W4 "-G 1A16, <br /> CONTRACTOR LICENSE# 48.1ICC CERTIFICATION# 02` <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have leen satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank„ any pray 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 re • tered rofessional ep&cer hav'q&education and e?c 'ence with underground storage tank stern installations. <br /> SIG OF TANK OWNER OR OWNER'S AGENT DATE 484PRONE 487• <br /> 0�//0/0 C( Z/A S7c?3/_ <br /> tRTIFIER'$VAIv11;(print) 489 CER'i^7FIER'S TrTLB: 486. <br /> .1 �/'C V f✓dam^-" K�NAME OF CERTIFIER-S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR. <br /> ;.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> +�++r��' ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(1=907) <br />