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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> I. FACIIdTY INFORMATION <br /> FACILITY m#(Agenry Use Onfy) t. <br /> BUSINESS NAME(S.me u FArnm NAMI?mDHA—DotvaHusmm Ae) 3, <br /> pQ:) TVlakiel �lpLZa— <br /> BUSINESS SITE ADDRESS tm. CITY IN. <br /> iabOG S- lFaAauv 6 allnv <br /> 11. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check an that gpolvt 4Oe WORK AUTHORIZED UNDER PERMIT 413k <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT _ <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 40, <br /> Lreylf>Lcc(uei�F OA K0 r5 v, cGc-, t 4a-(,LV- (- ) <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION eea <br /> Ste' <Q- StTk--tt 0-V1 :Ltis4puvs G . <br /> CONTRACTOR LICENSE# 4n4 1CC CERTIFICATION# 1e2a <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 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 a registered professional engineer inaving education and experience with underground storage tank s stem installations, <br /> SIGNATUREOF TANK OWNER OR OWNER'S AGENT DATE a I PHONE W. <br /> � ' u �t t (0 .aOu (401' ) -213-660 F <br /> CERTIFIER'S NAME(print) 1B5 CERTIFIER'S TITLE: e1C <br /> P"-: ilJ l(, WG-iT74kA1,/ (c t.(Ct t.C21l, <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 40, <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> S,P—V-(,(tt" , y t(A.x104'1 S $r..(�i.LC , �l u((,'_ ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(722007) <br />