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11 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(0- them per proiL) <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />BUSINES/S^ NAh[E(mssFACR.=NAWorDaA-D a sAe) 3. <br />W <br />BUSINESS $ZrMdO <br />IgOtt 61� <br />CITY 104. <br />8 C <br />EL INSTALLATION, MODIFICATION PROJECT DESCWPTION <br />TYPE OF PRQW= (Cbwk A tha AMbf) 493jL <br />WORK AUTHORIZED UNDER PERMIT 41W- <br />13 1. TANK INSTALLATION OR REPLACEMENT <br />(Number a De*. <br />PIPIDiG INSTALLATION OR REPLACEMENT <br />P3. <br />3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTABRAENT INSTALLATION OR REPLACEMENT <br />S. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: ea3a <br />37-P <br />sem- JV& sz�uvr, <br />f117 --# 71�m6 <br />ZYi?-qP 2-6 (t GQ g2 <br />IlL CONTRACTOR INFORMATION <br />NAME OFp-W�HO PERFORMED INSTALLATION / MODIFICATION <br />CONTRACTOR LICENSE # <br />ICC CERTIFICATION # 5Z iy ^� °�` <br />j `� C`J1 <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, acemrate, and that the following conditions have been , <br />• The installer has and the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any pay piping+ and any, secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's 'installation checklist has been completed. <br />The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a fessional engineer havinghLving education and ex ence with un d prateaksystem installations. <br />SIGMA OF TANK OWNER OR OWNER'S AGENT <br />DATE/ <br />`PH�O�N�E �� � 4P. <br />)q 7 <br />1/-•C/ <br />485 CERTIFIER'$ NAME �' �fi (GLs <br />CERT�[[ER'S TITLE Fella' <br />NAME OF CERTiFIER'S EMPLOYER (DBA) <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 469• <br />❑ 1NOWNER ❑ 2 TANK OPERATOR <br />RACTOR ❑ 4. PROPERTY OWNER <br />(�j/3. CONTRACTOR <br />[:15. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF LIST -C -1/2 Rev. (I2/20e7) <br />