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IED PROGRAM CONSOLIDATED FOI <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (One form per project) <br /> 1.FACILITY IDENTIFICATION _ <br /> FACILI'I Y ID#(Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NA or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS CfIY 104 <br /> II.INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> IYPE OF PROJECI (Check all that apply) 483aW012K AU"fHORIZED UNDER PERMIT 483L <br /> 1.TANK INSTALLATION OR REPLACEMENT (Number of 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 483C <br /> III.CONTILICI'OR L\FORNIA'CION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4Ka <br /> CONTRACTOR LICENSE# 4826 I ICC CERTIFICATION# 482. <br /> IV.CERTIFICATION <br /> 1 certifv that the information provided herin 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 undergound storage tank,any primary piping,and any secondary containment was installed according to applicable voluntary consensus standards and <br /> any manufacturers 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 by a registered professional <br /> engineer having education and experience with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 497 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE 486 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489e <br /> I.TANK OWNER 2.TANK OWNER <br /> 3,CONTRACTOR 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C <br />