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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One limn per project. ) <br /> I. FACILITY INFORMATION <br /> FACILI'Il' ID # (Agency t?se Only) <br /> BUSINESS NAME (same. uFAC11.rFYNXNu: or3. <br /> G 1v) � , <br /> BUSINESS SITE ADDRESS tn3. CITY 10-1.C � es <br /> II . INSTALLATION / MODIFICATION PROJEC ESCRIPTION <br /> TYPE OF PROJECT (Check all that aonh ) 4e3a. WORKAUTHORIZED UNDER PERMIT 4831' <br /> ❑ 1 . 'I'ANK INSTALLA'1lON OR REPLACEMENT (Number or Dale): <br /> ❑ 2. PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3 . SUMP INSTALLATION OR REPLACEMENT <br /> 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S. OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> `� k Qunl� 6 i5er rg1C�ce� <br /> ~�-anlL &sS 1 Z L► P i CbrT <br /> 1 <br /> C�� Cis <br /> Ill. CONTRACTOR INFORMATION I VNI ` ?" `, ' • _" k ' <br /> NA E OF CON'1aRACl�OR \v1-10 PERFORMED INS'T'ALLATION / MODIFICA'110N 4821 <br /> ont cr)cT �e ( Q C <br /> CONTRACTOR LICENSE f{ 4R2b. ICC CI tTIFICATIJ2N H 4822 <br /> IV. CERTIFICATION `f <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 /> SIGNATURE OI' TANK OWNER OR OWNE' R ' S AGENT DATE asa. PHONE 487. <br /> k f )k� AC & -Zo <br /> CERTIFIER <br /> ``' S NAME ( pri", 485 CER'I'IPIEWS TITLE : 48(', <br /> 1mec <br /> NAME OF CERTIFIER 'S EMPLOYER ( DBA) 188 CF.R'PIFIER 'S RELATIONSHIP TO TANK OWNER 489. <br /> �. ❑ L TANK OWNER ❑ 2 . TANK OPERATOR <br /> 3 . CONTRACTOR ❑ 4. PROPERTY OWNER <br /> �C \ ❑ i , OTHER AUTHORIZED AGENT Or TANK OWNER <br /> UPCF UST-C - 1 /2 Rel. ( 12/2007) <br />