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i <br />F-7 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project.) <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME (Same as FACBdrY NAME or DBA - Doing Business As) ; <br />Cv,*00 <br />Jack -;., -4L <br />BUSINESS SITE ADDRESS 103. <br />trry 104 <br />1 aA <br />II. INS ALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that aonly) 483& <br />WORK AUTHORIZED UNDER PERMIT 4X31, <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />-��L2. PIPING INSTALLATION OR REPLACEMENT <br />3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />�{ <br />S. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c <br />New Vtic f ?A*%,e,+Mfims, <br />Oew fahk. sumes a, -.A peoi,+r-ctfYoxS, , <br />NeW p;p;" from tit. ��;teina�ie� + -e.x;SfiKq p;P%►�. <br />1, <br />Repair of vew+ box- a,, -X new Pege+/,c,4%o, s,, <br />Ill. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482& <br />DU)VA Q KA lO0A+r cOn'f'rdLc~five's LAc <br />CONTRACTOR LICENSE # I 7,aszb. <br />ICC CERTIFICATION # � � � � � �� <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 />b registered professional engineer having education and ex erience with underground storage tanksystem installations. <br />SIGN OR OWNER'S AGENT <br />DATE 494• <br />PHONE 487. <br />1 <br />IFIER' AME (pent) 485 <br />CERTIF 'S TITLE: 496. <br />NAME OF CERTIFIER'S EMPLOYE (DBA) 498 <br />CERT(F EIVS RELATIONSHIP TO TANK OWNER 489 <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />and COV4"Y rNb-G.,110-W A04 <br />CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (12/2007) <br />