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UST Installatid,n -Certificate of Compliance Form Instructions <br /> (Formerly S`VRCE Form C) <br /> This Certification form must be submitted upon. the completion of installation or upgrading of tanks atl'er piping associated with a <br /> UST system. A separate form is required for each tank or, in the case of cotnpartracUtalizc(l tanks,tank compar=enr. This farm must <br /> be completed by the UST owner or an authorized representative of the owner. Please number all pages of your submittal. (Note: <br /> Numbering of these instructions follows the UPCF data element u=bcrs on the Certification form.) <br /> I- FACILITY ID NUMBER-This space is for agency use only. <br /> 3. BUSINESS NAME-Enter the complete Facility Name. <br /> 476. ADDRESS-Enter the street address where the tank is located. <br /> 477. TANK ID NUN SER- If[he UST owner has assigned an in-house rank ID number to this tank, enter that number in this space. <br /> This is the same as item 432 on the UPCF UST-Tank Page 1. <br /> 478. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER-Check this box to certify that the installer of this <br /> tank system has been traincd and certified by the tank and piping equipment mainufacturtr(s). <br /> 479. REGISTERED.ENGI'vEER INSPECTION - Check this box if the installation was inspected and certified by a registered <br /> professional engineer(PE). <br /> 480. UN-MED PROGRAM AGENCY EVSPECTION-Check this box if the installation was inspected and approved by the Certified <br /> Unified Program.Agency (CLTPA)or authorized Participating Agency(PA). <br /> 481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check this box to certify that all work listed on equipment <br /> manufactmcrs'installation checklists was completed. <br /> 482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check this box to certify that the installer <br /> possesses all certifications and/or licenses the CSLB requires for installation'uparading of UST systcras, <br /> 483. APPLICABLE STANDARDS AND PROCEDURES - Check this box to certify that the UST system was installed according to <br /> all applicable voluntary eorisensus standards and rnanufacturtr's written installation instructions. <br /> DESCRIPTION OF WORK - In the space provided, describe the work performed. Specify the type and the extent of work <br /> completed on this tank system (c.g. installation of complete tank system, installation of dispenser secondary containment, <br /> replacement of product piping, installation of turbine stumps, etc.). <br /> SIGNATURE OF TANK OWNER/AGENT - The tank owner or an authori2ed agent of the owner shall sign in the space <br /> provided. This signature certifies that the signer believes that all the information submitted is true and accurate. <br /> 484. DATE CERTIFIED-Enter the date the Certification was signed. <br /> 485. TANK OWNER/AGENT NAME-Enter the full printed name of the personsigning the Certification. <br /> 486. TANK OWNER/AGENT TITLE-Enter the title of the person signing the Certification. <br /> (Note: It is mandatory that items 478,481,482, and 483 be certified. In addition, you must certify that the inspections in either item <br /> 479 or item 480 have been performed.) <br /> UPCF(1157)flw(wre-c-2/2 brtp://www.unidocs.org Rev.02/15100 <br /> L � aH N00_1_� HL_�IJ E€bE 89b60L i 9I Et3t3�l9G1liI <br />