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'UNIFIEI) PI20GItAM.COIYSOLTIIAT'EI) FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />_ I. FACILITY INFORMATION <br />FACILITY ID H (Agency Use Only) <br />?. <br />BUSINESS NAME (Same as Faeiti& Name or DBA- Doing BwinesrAs) a. <br />1 t,LC "Pr,k a¢. <br />BUSINESS SITE ADDRESS rm. <br />CITY IM. <br />II.' INSTALLATION/ MODIFICATION; PROJECT.DESCRIPTION <br />TYPE OF PROJECT (Check all char aoaly) 4r.. <br />WORK AUTHORIZED UNDER PERMIT 4s7a <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />[14. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />!� cJ. (1 fi r� Q <br />o 1 (f v <br />S. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: ° a <br />6 lR,Pkc_ce_ Ow�St� Cu.a� - l�t rm <br />(� i d S 'fug f L 5 - 3 SG ( ':f- u.v. C,b c r.1; wy +-e-, <br />ltic_e �.vv. t'a' v 1v'r 4e e:S2 <br />;IIT CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 44=� <br />V YL C. -c. A cC fu:., <br />CONTRACTOR LICENSE # f -` ICC CERTMCA71ON'A 48" <br />UU • 7 U/ <br />IV. <br />I certify that 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 applicable <br />voluntary consensus standards and 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 <br />by aregistered rofessional engineer having education and a erience with underground storage tanks stem installations. <br />SI ' TURE OFT NK OWNER OR OWNER'S AGENT <br />DATI, 484 <br />PHONE P. <br />�,/3 Le <br />(909)'40-633-7 <br />.� <br />CERTIFIEFN�AME (print) <br />ALL <br />CERTIFIEWS TITLE: , 4E. <br />-3erJLC-ee Tech <br />1 �unc� e Z <br />NAME dt.�tRTIFIER'S EMPLOYER (DBA) 4sa <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />/+ <br />�/ Co r) �rL.-c6y, , -1- h G!'CONTRACTOR <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />❑ 4. PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Ree. (1272007) -12 www.unidomore <br />z d ZbE9T9bGoe ouI suO-40eu1u03 nI a4113 e8a:90 ZO ET tanC <br />