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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> F7 (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t' <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. <br /> BUSINESS SITE ADDRESS ( 103. CITY 104. <br /> II. NSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoolvl 483& WORK AUTHORIZED UNDER PERMIT 483b' <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Nu ber or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT sZ <br /> ® 3.SUMP INSTALLATION OR REPLACEMENT <br /> ($ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT � / -&/0 <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483`. <br /> 1 <br /> f <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> CONTRACTOR LICENSE# / 4121. ICC CERTIFICATION# ;� 482. <br /> r <br /> Y� 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 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 tanks stem installations. <br /> SIGNA ANK OWNER OR OWNER'S AGENTpp DATE 494. PHONE 487. <br /> z zGi1 ?J2o0U� 517/0 <br /> CE FIER'S N E 4t) � 485' CERTIFIER'S TI 496. <br /> < < VVI e✓ <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> C' � ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> CONTRACTOR ❑ 4.PROPERTY OWNER <br /> C/V\ V ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidoes.org <br />