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gn <br /> UNIFIED PROGRAM CONSOLIDATED FORM ___.. . Oq.-_ ..... <br /> UNDERGROUND STORAGE TANK & CTS®�N 41 COUN <br /> CERTIFICATION OF INSTALLATION/ ODIFICA �� 7), <br /> (One forni perLT.- <br /> FACILITY ID#(Agency Use Only) l.,S <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) '3 <br /> BUSrNES9 SITE 4. <br /> D l SS t CITY 104. <br /> C. , <br /> .,�sT�s.�,. co�r io�i��cAQN RO �c��r�s Teo <br /> TYPE OF PROJECT Check all that anafv) 413a ax3b. <br /> WORK AUTHORIZED CINDER PERMIT <br /> © 1.TANK INSTALLATION OR REPLACEMENT (Number or Date):2.PIPING INSTALLATION OR <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> J��UJ Gt CJ T G. <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT �. � <br /> 5.OTHER <br /> ESCRIPTION OF WORK BEING CERTIFIED: <br /> ax3<, <br /> e���C�C6-5(ai1 C 1�' i 3 �.0 ,rcC, w)-)e'Cti�� Gal <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482L <br /> - cj I-IC 'tt kC ' <br /> CONTRACTOR LICENSE# 4M, ICC CERTIFICATION# � <br /> At <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 instaIIed 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 Iocal agency,inspected and certified <br /> by a registered professional engineer having education and experience with under ound storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494• 1 PHONE �. <br /> -ERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 496. <br /> NAME OF CERTIFIER'S EMPLOYER BAk 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 48Y. <br /> l 7-6 �J 6�C�CC,� J Q 1.TANK OWNER Q 2.TANK OPERATOR <br /> 25:55 4c �K'�,1� 'S� 'S,3.CONTRACTOR Q 4.PROPERTY OWNER <br /> !1526 0 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(1212007)-112 www.unidoes.org <br /> T -d 2bE9 T 9b60Z ou I sioloeJ41J00 AI 94 T T 3 e96 :LO 20 22 i nr <br />