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iO, <br /> RECE! <br /> I;NIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK SM JO <br /> CERTIFICATION OF INSTALLATION / ODIFI A MENr L <br /> (One form per project) LTF/®EpgRr AL <br /> I. FACILITY.INFORMATION <br /> FACILITY ID#(Agency Use Onh) <br /> BUSINESS NAME(Same as Facility Na�mee or DBA—Doing Business iia) 3. <br /> { IL g 6 t <br /> BUSINESS SITE ADDRESS 103- CITY 104. <br /> 1L 0t l�) . ,wq `3q t,na�! CA <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Chech-all that a,RglvJ 483a WORK AUTHORIZED UNDER PERMIT 433r. <br /> ❑ 1.TANK.INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP NSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 0,0 5 33`f If <br /> 15t5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> E-t i+e \v Co,<1' i-c � Inc, <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c. <br /> N. CERTIFICATION <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 Iocal agency, or if required by the local agency, inspected and certified <br /> by a registered professional engineer having,education and ex erience with underground storage tanks stem installations. <br /> �SI NWrURE OF TA: K OWNER OR OWNER'S AGENT DATE 484- PHONE 487. <br /> � A4 ` t'�� (��r ) 'fl��- 6,33,7 <br /> CERTIFIER'S AIME(print) 495' CERTIFIER'S TITLE: 1, 486. <br /> Ua ! L <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> i j Y/ _ ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> �JJv <br /> ( \A-e 1 Coo l�� C c' T i 1 L ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ..5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.ore <br /> T -d 21,69 T 9i,60;3 ou I sjo-4oe.a,4uo0 ^I 84 T T 3 eGtr =0 T ZO 90 ReW <br />