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U MiD PROGRAM CONSOLIDATED FORAN <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATIONIMODIFICATION (One fore]per project) <br /> 1.FACILITY IDENTIFICATION <br /> FACILITY ID d(Agency Use Only) <br /> BUSINESS NAME(Sameas FACILIWNA or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS CI IY 104 <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPF.OF PROJECT(Check al l that apply) 481, 'AORKAU IHORIZED UNDER PERM IT 4836 <br /> I.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 REPLACEM INT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED 4s3C <br /> 111.CON fRAC'FOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> CONTRACTOR LICENSE p 4626 ICC CERTIFICATION k 492c <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 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 1 PHONE 487 <br /> CERTIFIER'S NAME(print) 465 CERTIFIER'S TITLE 466 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4E6 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489a <br /> 1.TANK OWNER 2.TANK OWNER <br /> 3.CONTRACTOR 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF us-C <br />