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I. FACILITY INFORMATION <br />ACILITY ID # (Agency Use On <br />IUSINESS NAME (Same as FAcrury NAME or DBA - Doing Businen As) <br />USINESS SITE AITDRESS gym• CITY <br />o <br />II. INSTALLATION/ MODIFICATION PRO <br />TYPE OF PROJECT (Check all that anD1v) 4& <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />WORK BEING CER <br />CONTRACTOR LICENS # <br />4� V1 <br />MIDESCRUMON <br />WORK AUTHORIZED UNDER PERMIT <br />(Number or Date): / ®0 <br />6 (( <br />o <br />' V <br />ICC CERTIFICATI& # <br />5`3,1 r --c <br />IV. CERTIFICATION <br />io ct.� <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 professional engineer having education and experience with underground storage tank system inctMintinne <br />eV'UATT roc nr TAwnr nX1rkT'D <br />VG atl <br />CERTIFIER'S NAME (Pflint) <br />OARTO�Cr <br />NAME OF CERTIFIER'S EMPLOYER (DBA) <br />494. <br />CERTIFIER'S TITLE:4 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />❑ I . TANK OWNER Cl 2. TANK OPERATOR <br />CONTRACTOR ❑ 4. PROPERTY OWNER <br />S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />K <br />UPCF UST -C -1/2 <br />Rev. (12/2007) <br />I <br />