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U ED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (One Icon per project) <br /> I.FACILITY IDENT]FICATION <br /> FACILITY ID 4(Agency Use Only) I <br /> BUSINESS NAME(Same u FACILITY NAXIE or DBA-Mir,Business As) 3 <br /> BUSINESS SITE ADDRESS CITY 104 <br /> M` II.INSJ'ALLA'FION/VIODIFICA'r10N PROJECT DESCRIPTION <br /> TYPE OI:PRO.IECF(Check all that apply) i8:a WORK AUFHORIZED UNDFR PERMIT 48;b <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 /> HI.CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> CONTRACTOR LICENSE 4 482b I ICC CERTIFICATION 4 492. <br /> IV.CERTIFICATION <br /> I certify 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 in23 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 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 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 487 <br /> CERTIFIEWS NAME(print) 485 CERTIFIER'S TITLE 4e <br /> NAME OF CERTIFIERS EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER Ossa <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 />