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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> f One r <br /> fom per pro3mt) <br /> FACILITY IDa(Agenq'Ux On/y/ L FACILITY INFORMATION <br /> BUSINESS — _ <br /> '/ ESS NAME(g.,••rncum NAS&r MA_ <br /> BUSIN S SRE ADDRESS <br /> CITY <br /> tl. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check ell�hpt em,ly) <br /> I TANK INSTAI.LA'ITON OR REPLACEMENT Xtra WORK AUT11ORIZED UNDER PERMIT +em <br /> e•2 PIPING INSTALLATION OR REPLACEMENT' <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT lNumhcr or Uatc) <br /> ❑ 4.UNDFR DISPENSER CONTAINM17NT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED. <br /> 4&�a N .u. <br /> ryy �tf clot- t/z 4.,d3/y. <br /> NAMEOFNCON/T�RyA,CTOR WHO PERFORMED INSTALLATION/CONTRACTOR <br /> IM ACTOR INFORMATION <br /> V`% arta <br /> CONTRACTOR LICENS'M <br /> 481 IC'C CERTIFICATION M <br /> Szve369 <br /> IV.CERTIFICATION <br /> 1 certifv that the information provided herein is true,accurate.and'bat the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and th). <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 instroctions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • 'fhe installation has been inspected and approved by the local a enc or if required b the local agency, <br /> b are istered rofessional en ineer havin education and ex rience with unde round at e g y, inspected and certified <br /> SIGNATURE FTANKO FROROWNER'SAGENT tanks St em installations. <br /> • DATE PHONE <br /> sn <br /> cERn IF'.R'sNAME(print) <br /> ne CERTIFIER'S 11TLE: <br /> US S ue <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) <br /> y CERTIFIER'S RELATIONSHIP TO TANK OWNER .n <br /> /i3•.c 6a9G1 / G• (JI.TANK OWNER ❑ 2.TANK OPERATOR <br /> f l/� 433F� .w'-3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> / 13 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> 17CF UST.0-IQ <br /> VIAL= <br /> — <br /> AN 0 7 2016 <br />