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s^ 1D PROGRAMOs r1 s UNDERGROUNDSTORAGETANK1 CERTIFICATION OF INSTALLATION form per pro] 1. I O • i _ FACILITY ID # (Agency Use Only) — _ � _. A —Doing Business As) BUSINESS NAME (same as FACILM NAME or DB 1 g _ gg �l A 1..�I i.. � .. ta' P II. INSTALLATION/ MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT (Check all that a MW 493. WORK AUTHORIZED UNDER PERMIT ❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT ❑ 3. SUMP INSTALLATION OR REPLACEMENT ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT $T. 5. OTHER III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION CONTRACTOR LICENSE # 4826' ICC CERTIFICATION # , IV. CERTMCA7JON I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. • All work listed in the manufacturer's installation checklist has been completed. • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified t a re istered professional engineer having education and ex rience with underground storage tanks stem installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494 PHONE A . A —_1 ® . 4e7 CERTIFIER'S NAME (print) aakr, NAME OF CERTIFIER'S EMPLOYER (DBA) UPCF UST -C -1/2 QJ1 & ( ) L CERTIFIER'S TIME: _ l 48e CERTIFIER' RELATIONSHIP TO TANK OWNER ❑ 1. TANK OWNER ❑ 2. TANK OPERATOR 3. CONTRACTOR ❑ 4. PROPERTY OWNER ® ❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER Rev. (I2aor)