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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />I ,ACII ITY INFORMATION' <br />FACILITY IDN (Agency Use Only) <br />A <br />BUSINESS NAME (Game as Fac!(iry Name or DBA— Doing Business As) 3,.. <br />i tZ.f. Pr l OLQ- <br />BUSINESS SITE ADDRESS im. <br />53110 Nw 49 <br />CITY <br />(?t perr. <br />II: INSTALLATION /MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Cheri all char annly) 433a <br />❑ I. TANK INSTALLATION OR REPLACEMENT <br />WORK AUTHORIZED UNDER PERMIT Orb. <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATTON OR REPLACEMENT <br />,2'5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 400, <br />ePk0.f a.e.. ek t. a. Ja - C �ifii.r rh <br />Cr1 L 5 - 3 S \ `--kXV., ,coal V'I }est' •%-e tvtu tND• "'.t� <br />>� w ; E N .n s �P M 6L17 lk p�,� �Q I a..._ <br />III CONTRACTOR INFORMAT16N'- .. <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 4sa. <br />lU y4rc�clrt- — <br />Inc -CONTRACTOR LICENSE N ICC CERTIFICATION N <br />IV CERTIFICATION <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 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 <br />a registered professional engineer having education and exI erience with underground storage tank system installations. <br />SIG TUAE OFT K OWNER OR OWNER'S AGENT <br />DAT w <br />PHONE 4V. <br />�''�/3 ©E <br />qt, 337 <br />CERTIF�N (print) 9tl5' <br />�t�Grez <br />CERTIFIER'S TITLE: 4w' <br />,�QLCe Tech <br />Ac� <br />NAME dF otRTIFIF-R'S EMPLOYER (DBA) ' <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 419. <br />j /� <br />vton ��,C6y 'nL <br />l� 1. <br />ElL TANK OWNER ❑ 2. TANK OPERATOR <br />�SCONTRACTOR El 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.unidocs.org <br />T'd ZbE9T9bG0Z DUI SJO-4oeU1000 ni 0'4113 dab:ZO 20 ST InC <br />