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08-22-'08 11;53 FROM-WENDT CONSTR. 1-209-547-9312 T-960 P02/03 U-862 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />i <br />FCERTIFICATION OF INSTALLATION / MODIFICATION <br />(One fOnn per project.) <br />I. FACILITY INFORMATION <br />FACILITY IO # (_4gaocy Use Only) �• <br />BUSINESS NAME(wm pAriLffY NANtE O I)$A - Doing Bmims As) 3, <br />BUSS SS SITE ADDRESS IW <br />302a (1,0jAfTd- <br />CITY <br />, • <br />ti. INSTALLATION/ MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check dLtbst aaoly) 483a <br />WORK AUTHORIZED UNDER PERMIT 42W <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />5k 00 S`zl 7 a 0 <br />S. OTHER <br />ESCRIPTION OF WORK BEING CERT1FlE0: a 3e <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION :a <br />11-6 V-1. <br />CONTRACTOR LICENSE # ° <br />ICC CERTIFICATION s d89m <br />3 6n <br />9 8 <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 r cred ional engineer having education and ex erience with underground storapte tank s stem installations. <br />SIGNATU ER'S AGENT <br />DATFr, <br />E10NE <br />�OWER <br />�iL7 <br />/ hdsi. <br />0"34 V <br />CERTIFiER'S j <br />1�ws <br />7ww <br />CERTIF S T td; 4S6. <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 438 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 'u <br />❑ 1. TANK OWNER Cl 2. TANK OPERATOR <br />Qq� (�� o <br />❑ CONTRACTOR ❑ 4. PROPERTY OWNER <br />.. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C- 1lZ Rev, (I2l 007) <br />