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.. ar/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One farm per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY IDM(Agency Use Only) 1' <br /> BUSINESS NAME(s.w.u FAC6rtY NAME w DBA-Duna B.—MI t <br /> k ISA <br /> BUSINESS SITE ADDRESS 10. CITY ta. <br /> X133 qC& vS6— Rca, '-+6c L`IO k I <br /> 11. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that armly) LLL WORK AUTHORIZED UNDER PERMIT aua <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 W <br /> rq 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: AM <br /> B <br /> (V-e- ! u>L q bot u=e�0-t,V- C In <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 41U <br /> AV)(�— PwLl 't A.c.. <br /> CONTRACTOR LICENSE M °1ra. ICC CERTIFICATION M °83c <br /> IV.CERTIFICATION <br /> 1 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 having education and ex erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE <ee PHONE 17. <br /> V. ASl aOl U ('fb� ) X13-1FC13b' <br /> CERTIFIER'S NAME Ont) 485 CERTIFIER'S TITLE: 4M� <br /> KRCZt-i u \l, WG L-Ug R)*J cy 0��,`ce✓ <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 489 CERTIFI 5 RELATIONSHIP TO TANK OWNER 439. <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> CONTRACTOR ❑ 4.PROPERTY OWNER <br /> V-Q.O J J .tet ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(13/200'/) <br />