COMPLIANCE INFO_2007-2009 - Laserfiche WebLink

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A& crp NIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION/MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 7* BUSINESS NAME(Same as FACn.rrY NAME or DBA—Doing Business As) 3 :C0V-0, BUSINESS SITE ADDRESS 103 CITY 104 II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that apply) 483a WORK AUTHORIZED UNDER PERMIT 4836. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ei ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 5.OTHER DESCRIPTION OF WORK BEING CERTIFIED: S 483c t v III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a e� s C— CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 48zc. 41T C I IV.CERTIFICATION 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 by a registered professional engineer having education and ex erience with underground storage tanks stem installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. it L ( ) CERTIFIER'S NAME( ri ) 485 CERTIFIER'S TITLE: 486. NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S ALATIONSHIP TO TANK OWNER 489. 1 [:11.TANK OWNER [12.TANK OPERATOR U y C a3.CONTRACTOR ❑ 4.PROPERTY OWNER ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST-C-1/2 Rev.(12/2007)