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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/ MODIFICATION <br /> cane Penn,per project.; <br /> I. FACILITY INFORMATION <br /> FACILITY Ina(a&mcy Use Only) � <br /> OU"ESS NAME(gene x FAC[LrrY NAMI01 1111A-11,10J OutMei Ail <br /> sU51NESS SITE ADDRESS u3, CITY <br /> of <br /> It. I.NSTAL TION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROI ECT(Check all that AMe) aysi WORK AUTHC)PIZED UNDER PERMIT <br /> Q 1.TANK INSTALLATION OR REPLACE rMENT (Number or Date); <br /> 3.SUMP INSTALLATION OR <br /> R RERGBLL �EN�L�IR��tJ¢ �"���,��� q <br /> C] n'.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.QTFHER <br /> DESCRIPTION IF WORK BEING CERTIFIED; <br /> -410 <br /> III. CONTRACTOR INFOXMATION <br /> N�E pF gN�T'IZACTQR t'P I�O PERFORMED INSTALLATION/MQDI CATIQN aLIL <br /> CO R LICENSE a ��' ICC CERTIFICATION a u+� <br /> �4 «101 917 1' <br /> IV.CERTIFICATION <br /> I certify Mat the information provided herein 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 underground storage tank, any primary piping, and any secondary containment was installed according to applicabic <br /> voluntary consensus standards and any manufacturer's writtcn installation instructions. <br /> All work listed in the manufacturer's installation checklist has bccn completed. <br /> The insta]Stion has beer[ inspected and approved by the local agency, or if required by the local agency, inspected and ecrtifled <br /> --by a rem orafmional a education and experience with underpround store a tanks stem installations. <br /> IfF K R O GENT DATE +e*. PHONE 497. <br /> / (rte)'Y4�'r33 <br /> I{FIIE�R'S NAM pr nt) +85 CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(D8A) sst CERTIFIER'S RELATIONS141P TO TANK OWNER 439. <br /> I TANK OWNER 2.TANK OPERATOR <br /> Far-,>- 0 ,cOTRACTOR d,PROPGRrYOWNE <br /> R <br /> Q S.OTFIER AUTHOPUZED AGENT OF TANK OWNER <br /> UPCF UST,C-If2 <br /> Rev.(t2120117) <br />