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UNIFIED PROGRAM CONSOLIDATED FORM ;.;. <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION INSTALLATION/MODIFICAT19N <br /> `f (One f r project.)$ <br /> I. FACILITY INFORMATION '� <br /> FACILITY ID#(Agency Use Only) <br /> IN"J2.1 <br /> BUSINESS NAME(Same as FACHM NAME or DBA—Doing Business As) <br /> Cti,cUtr oo �r <br /> BUSINESS SITE ADDRESS CITY 104. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that wmW 481& WORK AUTHORIZED UNDER PERMIT 493b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Dau): -7/.V l I n <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT 9 <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT �`j(S Q J(_q G� <br /> 5.OTHER <br /> `C f <br /> DESCRIPTION <br /> gi OF WORK BEING CERTIFIED: 483e <br /> d( lea..``ems. V —-9LO S-E L"Ov 7 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> 50-U�Ce- 5 -fL0 vi -5 -s fini3O 1 itis <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# 4a2e <br /> IV.CERIVICATION <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 re 'stered professional engineer having education and experience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. 1 PHONE 77. <br /> V . 7f V <br /> f T a© -3--CQo S <br /> CERTIFIER'S NAME(print) 483 CERTIFIER'S TITLE: 486, <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 48iiCERTIFIER'§RELATIONSHIP TO TANK OWNER 489. <br /> ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> S ��C M3.CONTRACTOR [34.PROPERTY OWNER <br /> V u l ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-IR <br /> Rev.(122007) <br />