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Ax �5l161 /3 G� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK I D <br /> CERTIFI �ATION OF INSTALLATION/MODIFICA <br /> prejmL) <br /> 1. RACII,I'I:A",IVFOANIAi!10N , <br /> FACH.ITY ID#(Agemy Uee 0-1y) — <br /> BUSINESS NI(tME(s.e.dpnc❑.rry xn,�o�� �I:. ea�....•NI E <br /> HEALTH DEPARTMENT I . <br /> BUSINESS S AD <br /> D f - <br /> C <br /> Irr T rloN i i�Drl rcT�lp�t r�_o Cir n ' <br /> TYPE A KINSTALLATION <br /> NSTLLATIall OR REPL WORK AUTHORIZED UNDERPpRMIT aeob <br /> 0 1.TANK A'STALLA 71ONO R EPIAt DENT (Numberor Date): <br /> ❑ 2.PIPING INSTALLATION OR REPl.rt F_�¢NT <br /> Cl 3.SUMP INSTALLATION OR REPLA:. b ENT <br /> ❑ 4.UNDER DISPENSER CONTA]NME• 'IJ57ALLATION OR REPLACEMENT' <br /> .UNDER <br /> fV V Ill! 7 <br /> DESCRIPTION OF WORK BEING CERTU'j D <br /> ail <br /> NAME OF CO O R\Ir INSTA TIO MODEM TI N ems' <br /> CONTRACTOR LICENSE# „ -. 4e2b' ICC CERTIFICATION# wu. <br /> {: = <br /> _ _ Mclnrr <br /> I certify that the information provid.d herein is true,accurate,and that the following conditions have been satisfied <br /> • The installer has met the requirem ms set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, : 5) primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards an, ar y manufacturer's written installation instructions. <br /> • All work listed in the manufactur:. 's installation checklist has been completed. <br /> • The installation has been inspecte. and approved by the local agency,or if required by the local agency, inspected and certified <br /> istered professional engin! a Navin education and ex enence with and ground stow a tanks stem installations. <br /> 'I NATURE KO i.iGENT PHONE Ort. <br /> DATE 4ea, <br /> CERTIMER'S NAME 495 CERTIFIER' E, <br /> NAME O TIF7ER'S EMPLOYER A) CERTIFIER'S RELATIONSHIP TO TANK 4+v. <br /> 0 L TANK OWNER 0 2.TANK OPERATOR <br /> 0 3.CONTRACTOR 0 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF 1JSTC-1/2 <br /> Rev.(12/2007) <br /> T 'd ZbE9I9460Zi Su040eluuJ AI az113 d2E :21 61 01 ReW <br />