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From 11/03/2008 15 42 #164 P 022/033 <br /> UNIFIED PROGRAM CONSOLIDATED FO paw <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION I MODIFICATION <br /> (One form per project.) <br /> 1. FACILITY INFORMATION <br /> FAC1L[TY ID tt{Agency Use On(}J <br /> t. <br /> BUSINESS NAME((scone is Mcjiary NAME or DBA-Doing Buffness A:) Eli= 3 <br /> BUSINESS SITE ADDRESS ,u) CITY <br /> too. <br /> 1 S. ESc 1 ", F,.,cv�t <br /> 11. INSTALLATION!MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anoly) 183a 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 <br /> A.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> \ d63c <br /> --�n5�.1��2�o ro► ,®'°� newt G{��"' �ys°� ��-- �"rttl�. -#'� �l�kl <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION!MODIFICATION 482a <br /> / l7G �yl C` vl -,�v�C , <br /> CONTRACTOR LICENSE# 4826 I ICC CERTIFICATION# 482c <br /> r 7 <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 pLofpsional engineer havin education and ex erience with underground storage tank system installations. <br /> SIGN RE OFT ER OR OWNER'S AGENT DATE 484 PHONE 487 <br /> C TIFIE ' NA rint) 485 CERT,(FIER'S TITLE: 48e <br /> a <br /> NAME OF CERTIFIER MPLOYER(DBA) A88 CER RELATIONSHIP TO TANK OWNER 489 <br /> � Q 1.TANK OWNER 0 2.TANK OPERATOR <br /> 7-t �Ylcr4 C-tr7dl�j�N`LtG f I/lG , 3.CONTRACTOR El A.PROPERTY OWNER <br /> © <br /> S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST C-112 <br /> Rev.(17./2007) <br />