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UNIFIED PROGRAM CONSOLIDATED FORM <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 as FACILITY NAME or DBA—Doing Business As) 3. <br /> 1 ct c 'TC LA c k d- (k O-t L <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 30)4o t,[ . —Ir cu V-S o-C CA -7� <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION ' <br /> � r <br /> �.. ,:. d <br /> TYPE OF PROJECT(Check all that apply) 483x. 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 SR (}Q S <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: I 483c <br /> Rep i me-S -i-e-S-,- bo,,-t- -6 c d k e S e I w P S+ Sec 0 c'cQgr y <br /> CoJo-c-4' 11"c– <br /> E, J ' V ELI <br /> APR 2 0 2015 <br /> ENVIRONMENTAL <br /> QC�r^ Qr1rr!�pVr4ACAIr <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> (.--y-)+ra 1 M a t rx-F m a n e e- <br /> CONTRACTOR LICENSE# 482b' ICC CERTIFICATION# 482c. <br /> La L4 0 <br /> N 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 underground storage tank system installations. <br /> SIGNA RE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> ©-- /vof / )S' 4,?- - o <br /> CERTIFIER'S NAME(print) i 485 CERTIFIER'S TITLE: 486. <br /> 1- -e ri S kct j C, I---D <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) - 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> t' <br /> 9'3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />