Laserfiche WebLink
0 6 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/ MODIFICATION <br /> (One form per project.) <br /> 1. FACILITY INFORMATION <br /> FACILITY[D#(.agency Use Only) t. <br /> BUSINESS NAME(same.FACRJTY NAME m DBA Doing 9usmmsAs) <br /> 1>.,, $ C.. <br /> BUSINESS SITE ADDRESS F CITY 104. <br /> t t2 Ga< f4ve� �ycrrl®N e.A. <br /> 11. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check sll that apDW WORK AUTHORIZED UNDER PERMIT 48W <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date); <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT s�®OCotOg1 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> JW 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED; 483, <br /> CE t�-c t Fs{ -t'�,� �..-S �.s.4.A.�'C!4.... �-n®�.,. "t�.b.ra' b,.�3.a.••t •�j.,..,..G.p�L.. <br /> .+nL.4L— <br /> ID. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4823. <br /> 1z:^.r.vo r- +r.--�a� `a~¢is..`C.0- , - —,c.. <br /> CONTRACTOR LICENSE# 482b. [CC CERTIFICATION# 4820, <br /> pqg I 1B013Q4t4 — "-r <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 aregistered professional engineer having education and ex rience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> to/X%I to (yeu► )4�5�-logo <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 8 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> �v.wv.wvsr►�1s1v`C1+S <br /> [13.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> T7L <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(12/2007) <br />