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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per pmjem.) <br /> I. FACIIdTY INFORMATION <br /> FACILITY D)M(Agenry Use Only) <br /> BUSINESS NAME(sa�.�.u'Facomu�o,1AA-na,eeg .M) I <br /> BUSINESS SITE ADDRESS im. CITy IN <br /> l s(o bo S . H a-v ar.A R&— (_cl�*r v <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TWE OF PROIECT(Check all Nat eoolvl ma AUTHORIZED UNDER PERMIT anh <br /> AU <br /> WORK <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT WORK <br /> U Date); ) <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ S4.UNDER.OTHER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT S Q� L <br /> DESCRIPTION OF WORK BEING CERTIFIED: P eu. <br /> t ��(ace NVfAEW �Boc-,Gl w t(ei Cci(GLOkLL(- <br /> e ID. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION au. <br /> S-evV C`e S+D(-+L0'" S c+4 as ���C . <br /> CONTRACTOR LICENSE NICC aub. CERTIFICATION k ant <br /> IV.CERTIFICATION <br /> Y certify that the i!nd <br /> ation provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer ht the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The undergroutorage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consstandards and any manufacturer's written installation instructions. <br /> • All work listede manufacturer's installation checklist has been completed. <br /> • The installationbeen inspected and approved by the local agency,or if required by the local agency,inspected and certified <br /> are 'steredssional en ineer havin education and ex erience with under ound Stora a tank s stem instal]ations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4u. PHONE uv. <br /> ott%t w � 8 is' ao(0 ('fey ) - JU)4008 <br /> CERTIFIER'S NAME(print) aas CERTIFIER'S TITLE: aes. <br /> KAIZTIN 1!_ EtTfiMAnl ,tip e l ut it d <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) ora CERTIFIER'S RELATIONSHIP TO TANK OWNER aa. <br /> c ❑ ].TANK OWNER ❑ 2.TANK OPERATOR <br /> U�,�`U t /� �yr.� �^.S L��r y� 1,1R 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> Ce, `lc- J C ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST.0-12 <br /> Rev.(122007) <br />