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From 11/03/2008 15:42 #164 P 0211033 <br /> t.1NIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> :nem p:p, ect) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Ageng Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Dong Business As) 3 <br /> BUSINESS SITE ADDRESS to3 CITY <br /> 104 <br /> � 11 a r-c-tc+n &/1O�z- X ad r-.qrm)n <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> a81n. <br /> TYPE OF PROJECT{Check all that annly) WORK AUTHORIZED UNDER PERMIT agDb <br /> �i I TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 4g3t <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> CONTRACTOR LICENSE# ICC CERTIFICATION# 48>c. <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 containtnent 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 havinp,education and ex erience with under ound Storage tank system installations. <br /> SIGN RE OF TANK OVeR OR OWNER'S AGENT DATE 484 PHONE 497 <br /> k7- <br /> CERTIFIER' NA E(p t) 485 CERTIFIER'S TITLE: L_ell, <br /> ass <br /> NAME OF CERTIFIER'S LOYER(DBA) 488 CER i RELATIONSHIP TO TANK OWNER 4ff- <br /> 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ! c 1 r Vic r" Cp yl f J ih.°Lo yt� �, 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF(IST-C-I/2 <br /> Rev.(12/2007) <br />