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U ED PROGRAM CONSOLIDATED FORV <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATIONIMODIFICATION (one form per project) <br /> 1.FACILITY IDENTIFICATION <br /> FACILITY ID 9(Agency Use Only) i <br /> BUSINESS NAME(Same s FACMW NA or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS CITY too <br /> IL INSTALLATION/A10DIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483n WORK AU'I HOR[ZED UNDER PERM I 4816 <br /> 1.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 483C <br /> Ill.CONTRACTOR INFORN1A I'IO,N <br /> NAME OF CON FRAC WI 10 PERFORMED INSTALLATION/MODIFLCAIION 482. <br /> CONTRACTOR LICENSE N 4826 [CC CERTIFICATION 9 48x <br /> IV.CERTIFICATION <br /> certify that the information provided[term 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 lank,any primary piping and any secondary containment was installed according to applicable voluntary consensus standards and <br /> any manufacturer's written installation instructions. <br /> • All work listed in the manufacturers 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 4s7 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE 486 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <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 />