Laserfiche WebLink
UNIFIED PR®GGRAkM CONSOLIDATED)E`®R1VI <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> I. FACILITY IINFO TION. <br /> FACILITY ID#?(Agency Use Only) 3;- <br /> BUSINESS NAME(Same as FacllfN Name or DBA–Doing Business As) 3. <br /> lu"t -- <br /> BUSINfESS SITE 7ADDRESS 103• CI 104• <br /> /yi.l Y7 ,r ee <br /> :it .INSTALLATION[MODIFICATION PROJECT DESCRIPTION <br /> T <br /> TYPE OF PROJECT(Check all char aunly) 483a' WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 00 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> .9-5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 48U. <br /> /)� 1/1'Z,�i'k,t` v►'T'r�UtLf.� (,�Cc.'�a-C,.>;i 13^�l.C• FJGe� �!?5 C7'1 U,.., I✓r e ]-e..4, l�� <br /> LJ <br /> � - �, f?�,� fit. rr�,► �.fit . <br /> ,; IIL. CONTRACTOR INFO TION, <br /> NAME O CONTRACTOR WHO PERFORMED INSTALLATION 1 MODIFICATION' 482a. <br /> +. ®v <br /> CONTRACTOR LICENSE## bszb. ICC CERTIFICATION## 482`' <br /> . CERT�>�cATLaiv <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 /> !M a registered professional engineer having education and ex erience with underground storage tank system installations. <br /> SIGN TURE OFT K OWNER OR OWNER'S AGENT A bsb• PHONE 48T• <br /> 4/4e 1- (c 3,6 <br /> CERTIFIER'S N ME(print) 485 <br /> CERTIFIEWS TITLE: <br /> NAME OF k?tRTIFIER'S EMPLOYER(DBA) ' CERTIFIER'S RELATIONSHIP TO TANK OWNER 439' <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> y ,(• <br /> cm4m(4w , <br /> ,Erl CONTRACTOR ❑ 4.PROPERTY OWNER <br /> �� ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12f2007)-1/2 www.unidoes.org <br /> T 'd Zt,69I9b602 OU I SJ040e.a-4U®0 AI 91 t 13 e92 :80 20 61 unC <br />