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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I FACMTY INFORMATION <br /> FACILITYID#(Agency Use(?nlv). <br /> tL o i <br /> 5 -; 9 o <br /> BUSINESS NAME(Same W FadliWName or DBA—Doing Business As) 3: <br /> BUSINESssITEADDREss ias. CITY iw. <br /> o G C l . . , CIS EJ n c6 T.52b,--) <br /> II INSTAL CATION J MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all thce aan)y) °H'- WORK AUTHORIZED UNDER PERMIT 4 b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT T\`�j -L°C, <br /> 4•UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT J-LCI-Ul'r; <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4ax. <br /> �i1�'tc�ll V�zC1U("'PvLK.sI" �5�7Gc'�C�- 112 C\(�tt(t��tRC�}�;� 1i�Ltic1 5cn:1C(' C.�� ��ll • 'nP� <br /> 11�eciE:r rt_�c:� �rr.� 2C`rC` -112- c1i�cimtl^c',fiirc. lic�iic\ `x:,1�_.r �-tom Ft11`�•m� <br /> CKA T U q oc� <br /> III. CONTRACTOR IIVFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 482.. <br /> �In+rocf(r` dC . <br /> CONTRACTOR LICENSE# ° b ICC CERTIFICATION# °M. <br /> L�C�CC17 t 3-I <s:� <br /> 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 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 /> b <br /> registered professional engineer having education and exI erience with underground storage tank s stem installations. <br /> SIGN URE OF TANK OWNER OR OWNER'S AGENT DATE E °ar. <br /> 7 � �" "- — ZCx=I )GK9 I CGt�, <br /> C IFIER'S NAME(print) 4N5. CERTIFIER'S TITLE: 4a <br /> 1 -. TECH , <br /> NAME OF CER��TIF�IER''�S EMPLOYER(DBA) ,1 r� °Ba' CERTIFIER'S RELATIONSHIP TO TANK OWNER °m' <br /> EL k�- t `_C.�l�i"l(.\��"('�,� t4 c ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> b13.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(122007)-12 www.unidoc.org <br /> Z ,nl Zb6919b60Z OUI S-JOgoe,Jg000 Al a-4il3 LTS :80 20 60 iter <br />