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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per prof-t.) <br /> I. FACII.ITY INFO TION <br /> FACILITY 0#(Agency Use Only) t' <br /> BUSINESS NAME(Sam ACBdrY NAME/Q' DBDDA�,-^^Doing Businew As) 3. <br /> �4ri e V <br /> BUSINESS SITE ADDRESS f 103. CITY 104. <br /> tbu fir ICA <br /> i <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that a>roly) 453a WORK AUTHORIZED UNDER PERMIT 4536. <br /> 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION OR REPLACEMENT C� ®�� <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT J <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 41 <br /> 700 <br /> OIL <br /> tog <br /> r "��\�et\ ea rn it �►®5 � b c <br /> III. CONTRACTOR INF® TION <br /> NAMEt CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> CONTRACTOR UCEN9# ' ICC CERTIFICATION# 482c, <br /> 7S 5 0 2370 V1. <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satdsfied: <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 approval by the local agency,or if required by the local agency,inspected and certified <br /> by are 'stered Eafessional en ' ser having education and ex encs with and andstore a tank stem installations. <br /> SIG TURF OF TANK O ORO R'S AGENT DATE 484• PHONE 487• <br /> 7—b (5-30 )672-1182 <br /> CERTIFIEWS NAME t) ® 4M CERTIFIER'S TITLE: T9 <br /> rvice.. tr <br /> NAME OF CER 'S EMPLOYER(DBA) 40 CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. <br /> &1.TANK O ❑ 2.TANK OPERATOR <br /> 31.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />