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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> JIJL <br /> 13 2009 CERTIFICATION OF INSTALLATION/MODIFICATION <br /> IN (One form per project.) <br /> "fi� I. FACILITY INFORMATION <br /> FA I -� �,��•e Only) <br /> BUSINESS NAME(Same as FAC11M NAMEor DBA—Doing Basin As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDDly) 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 ' A&j' i <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> ff483t <br /> l s S it 1 L <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> vi �- 5 <br /> CONTRACTOR LICENSE# 4826• ICC CERTIFICATION# 482c. <br /> ll " f — <br /> UT- <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 registered 2rofessional engineer having education and experience with underground stora a tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE / 494. /PHONE ® 487. <br /> . <br /> CERTI IER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> f L- <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> l Cst"A 3_*co PA .CONTRACTOR ❑ 4.PROPERTY OWNER <br /> c . ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-IQ <br /> Rev.(I2t2oo7) <br />