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.. <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per Project) <br /> I. FACILITY INFORMATION <br /> FACILITY IDA(Agency Use Only) 3 <br /> BUSINESS NAME(Supe a FACalrY NA wDBA-Do.,Bumrns A,) 3 <br /> VII/C-4g-,- �c c-�.ulewfv, <br /> BUSMS SITE ADDRESS 303. CITY <br /> 3e, 4!57—. 44ai 2d. 4ial; G�1 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECTCheck all that apply) 4u. <br /> ( WORK AUTHORIZED UNDER PERMIT 4t3b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> Qr2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDFR DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: wa <br /> zer" 5i cold�.y c4 Ja3 ,nult� fci++1 na.arot1 C;"H,nys 4f trot l�LG.,d3/y. <br /> RECEIVED <br /> MAR 2 4 2016 <br /> (ENVIRONMENTAL <br /> ucA17vncPs T> vArr <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION au <br /> CONTRACTOR LICENS A 4831, ICC CERTIFICATION 1i Wk. <br /> `ydsgds-- S z vz369 <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 /> b a re istered rofessional en ineer havin education and ex erience with underground Stora a tanks stem installations. <br /> SIGNATURE FTANKO R OROWNER'S AGENT DATE 484 pHONE az <br /> CERTI IER'S NAME(print) 185 CERTIFIER'S TITLE: 486. <br /> 4 . <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 489 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> hc.✓N �c4q)f �sn5'�✓uc�ea+�/=j1C, ❑ <br /> I.TANK OWNER <br /> �G r�X 6o�cr ❑ 2.TANK OPERATOR <br /> fu� moi, �G X3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />