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& 0 <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 ID N(Agency Use Only) <br /> BUSINESS NAME(Same es FACILITY NAME or DBA—Doing Business A,) 3. <br /> S•4v t jo .j GfiT yy-Ip/ zmvwc <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> y?o t4i rrse/x;,le- X G N�.A✓z c.+ <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aooly) 483e. WORK AUDI IORIZED I R\DLR PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Datc): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> El .SUMP INSTALLATION OR REPLACEMENT <br /> ❑�31'DER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT Sk ooL ys4�� <br /> [?F5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> TN Slw // D�M lch�3 6, 'moo S,,4-1 Br 1*4,eW /4gt i.le-' <br /> A-Abe..: -6-rvo r *l Cx-) 'I l w .r�". ir z bpi) <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO/PERFORMED INSTAL�LA/TTION/MODIFICATION 48P <br /> CONTRACTOR LICENSE 4 4gzb. ICC CERTIFICATION H 482`. <br /> �'o�33 v if -/I A 2- r67a.C¢ y9(/ e///Z/b <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 profcsipnal en ineer having education and ex erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK O OR OWNER'S AGENT DATE 484. PHONE 487. <br /> Y- 7 - 20/3 ( 4 <br /> CERTIFIER'S N (print) 485 CERTIFIER'S TITLE: 486' <br /> .7 rs c y /u <br /> NAME/s STI EM��KA(DBA) _ 488 RELATIONSHIPO TAN 2.TANK OPERATOR 489. <br /> ❑ L TANK OWNER <br /> [k4'CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(122007) <br />