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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORINT <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t' <br /> BUSINESS NAME(Same as FACR=NAME or DBA—Doing Business As) 3• <br /> A2co &nZ2Ati <br /> BUSINESS SITE ADDRESS 103• CITY 104• <br /> �2c.m 0 Al J v2�C�c 1 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTI N <br /> TYPE OF PROJECT(Check all that avy 483x. 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 ®f\ <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT V t U <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> �s7v r7 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> —Tt LL <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c <br /> �� �l I <br /> IV.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 local agency,or if required by the local agency, inspected and certified <br /> by a re 'stered professional en ' eer having education and ex erience with under ound storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE t 484• PHONE 487. <br /> CER R'S AME(print) 485 CERTIFIER'S TITLE: 486• <br /> LTH C -i'1j <br /> NAME OF CERT.IFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(12/2007) <br />