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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t <br /> BUSINESS NAMEa as Facility Naor DBA-Doing Business As) 3 <br /> me <br /> BUSINESS SITE ADDRESS tai. CITY <br /> II• INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoolvl 483a WORK AUTHORIZED UNDER PERMIT 483e <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT D <br /> El �O / (� <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT /"- b '7 Zt-{- <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4sx. <br /> � JjAzoa /1 c57 P Zii$j A44, S A 1048073 a zsr, <br /> fPqC£O a <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482= <br /> /9if Co.RJ w <br /> CONTRACTOR LICENSE# OFneat I ICC CERTIFICATION# 482` <br /> lelgo)of3.r_ UC, <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 having education and ex 'ence with underground stow a tanks stem installations. <br /> SIGNATURE hA�QOWNER OR OWNER'S AGENT DATE _ 4e4. PHONE 487 <br /> IIwVII <br /> CER NAME(pont) 485' CERTIFIER' rPLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 4W <br /> ❑ 1.TANK OWNER go.TANK OPERATOR <br /> t�GC A , (41/{ �� <br /> 9-T.CONTRACTOR [14.PROPERTY OWNER <br /> l/ f ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UFCF UST-C Rev.(12IZ n-112 www.unidocs.org <br />