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'.,ep. 4 . 2 011 02:57 PM PAGE. 2/ 2 <br /> UNIFIED PROGRAM C".ONSOIADATET.1 FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> ((fin fnrm per prnjc-ct,) <br /> 1. FACILITY INFORMA•I'ION <br /> F'AC'Bl.,l'I'Y I!)#(Ageotc)-Use OnIY) � -7 <br /> TTTI <br /> 1' <br /> H1IS[NL'SS NA E(wn-FA('ILI'rY NAME-DBAA�-Owkig�k«ym„u A0 3 <br /> !W * 4/WUSINESS SC F.?Allilt CITY lua. <br /> It INSTALLATION/MODIFICATION PROJET DESC:RfPTION <br /> •rYPE OF PROJECT(Chock all that aM1j) 4x.14. WORK Alf rF1ORIZED UNDER PERMIT axah <br /> ® 1.'TANK INS'I ALLA•1•10N OR REPLACLIVIENT (Number or Date.): <br /> ® 2,PIPING INSTALLATION OR RMILACHNI N'r <br /> ❑ 1,SUMP INSTALLATION UR REPLACEMENT <br /> ❑ q NDFR DISPCNSr1.R('ONTAINMENT INSTALLATION OR RITZ AC HMENT,gc <br /> 5.(:)rrrIF:R - <br /> 17F.SC'RFPTi()N OF WORK IiFIN(i CF:R']iFlFif): tc <br /> C l£o/t 04-4 <br /> III. CONTRACTOR OR JNFORMATION <br /> NA. 't'1F C'UN'1'ItAC"1'OIt WH()1'PRFORMEI)INSTALLATION/MOUIFIC'A'I'LON Ix'" <br /> L Y Bvt. �--- <br /> xyh, IC('C..ERTIEICATION# <br /> (.'.ON'fRA(."rd)Ii L1CP.NSM# <br /> S;— <br /> IV.CERTIFI(.:ATION <br /> I certify that the information provided herein is true,pecurate,and that the following conditions hove been satisfied: <br /> a The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> a The underground storage tank, any primary piping, and any sewada)ry containn)ent was installed according to applicable <br /> voluntary consensus Standards and any manufacturer's writtcn installation instructions. <br /> • All work listed in the manufacttn•er's installation checklist has been COmpleled. <br /> • The installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> b are Uistered rCite55lUllal era,,it)eer havir) education and ex)erienec with under rutted storage tanks stent nstalla)tioos. <br /> SIGNATURE OFTANK OWNII,R Old OWNRR'S A(,F'NT I')A'rF ~� 484 1111ONP 4A7. <br /> --1 (4— <br /> CI RTIPI NAMr(I>Ilrtt �v x: CLiou'lrlLR's' t'1L ? -•/ x+; <br /> NAW IL 1'CURT] 'S FMPLOYFR(11FSA) 4xx C"•rF2"r►rlr:R'S RrU ATIONSHIP TO TANK OWNER <br /> ❑ I.'rANK(.)WNI:R ❑ 2.TANK ON'RA')'OR <br /> �.C ONTRAC FOR ❑ 4.PROPERTY OWNI?R <br /> [] 5.MI AUT't10110.0 AUUNT OF I'ANK OWN1,:It <br /> UPC '11 i'1'-C:-t/2 Rev.(12/201)7) <br />