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Jan.26.2010 04:17 PM PAGE. 3/ 3 <br /> 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROI)ND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per pro*0 <br /> 1, FACILITY INFORMATION <br /> FACILITY ID#(Agency Use CMIy) )' <br /> BUSINESS NAME(Syme es 1-'A.CILITY NAML or DDA- m8 nusinesz As) 3' <br /> BUSINESS SITE ADDRESS )03. CITY 104• <br /> 3(?q <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Chock a ll..that.manlv.) 499° WORK AUTIIORIZED UNDER PERMIT 400. <br /> [] 1.TANK INSTALLATION OR REPI.ACBMFNT (N)Jmber or Dato)' <br /> ® 2.PIPING INSTALLA:TION OR REPLACEMENT <br /> ® 3.SUMP INSTALLATION OR REPLACEMENT <br /> 13 4 NDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> OTHER <br /> '156,SCRIPT)ON OP W R :BEING CERTIFIE 1✓�3 /'G 483e <br /> �,S1.M/tG �t 0(,^ <br /> III. CONTRACTOR INFORMATION <br /> NZAM,OF CONTRACTOR WFIO PERFORMED INSTALLATION/ fFI ATION 4424• <br /> 1 O�c" o i'ti'( <br /> CONTRACTOR LIC6NSS# "2b' ICC CERTIFICATION# 42v.257 ' -0 -Ir <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 manufacturor's written installation instnictions. <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 rokisteredgrofessional engineer havingeducation and ex erience with underground storage tank system installations. <br /> SIGNA OF' K OWNER OWNER'S AGENT DATE 484, PHONE 437. <br /> C 'S NAME riot) 489 CERTIFIF„R' TITLE: <br /> akin <br /> NAM$OF CE IEK'S EMPLOYER(DBA) M CE3RTIFIER'S RELATIONSHIP TO TANK OWNER 439' <br /> Q 1,TANK OWN13K I] 2.TANK OPERATOR <br /> Z.a,CONTRACTOR 0 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNRR <br /> UPCF UST-C-I/a Rev,(1121=W) <br />