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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGET <br /> CERTIFICATION OF INSTALLATION1 MODIFICATION <br /> (One form per project.) <br /> L FACILITY INFORMATION <br /> FACILITY IDN(Agency Use Only) T - 7 F-F <br /> BUSINESS NAME(same as racmrry NAw«asA-Ddas Biwm=Aa) y <br /> BUSINESS SITE ADDRESS 104 <br /> 01 <br /> 0{n <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Chwk all that env) '"• WORK AUTHORIZED UNDER PERMIT 4s <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date)- <br /> 0 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 2!5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 493c <br /> ' -t s <br /> r i <br /> µdr.°rc f r <br /> `Q <br /> r; <br /> NOS 2 4 2010 <br /> CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 48ZL <br /> I <br /> CONTRACTOR LICENSE# 482b ICC CERTIFICATION# aaze <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 manufacturees 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 /> a rofessional engincerhavinit jyducation andever <br /> ce with under and sto a tank system installations, <br /> SIGN RE F K O OWN ENT DATE eU PHONE eat <br /> CERTIF! 'S NAME(print) ens CER FI S TITLE: e" <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 40 <br /> ® I TANK OWNER ❑ 2.TANK OPERATOR <br /> G?17CONTRACTOR [14.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C.1f2 <br /> Rev.(1212007) <br />