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IP <br /> U IED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (One form per project) <br /> 1.FACILITY IDFN'I'IFICATION <br /> FACILITY ID#(Agency Use Only) I <br /> BUSINESS NAME(Same.FACILITY NAME or DBA-Mir,Business As) 3 <br /> BUSINESS SITE ADDRESS CITY too <br /> 11.INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> IYPE OF PROJECT(Check all that apply) 183' WORK AU I I IORI/ED UNDER 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 /> III.CONTRACTOR INFORM(TION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 483a <br /> CONTRACTOR LICENSE# 482b ICC CERTIFICATION# 482e <br /> IV.CERTIFICATION <br /> 1 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 1 PHONE 487 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE 486 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 49% <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 />