Laserfiche WebLink
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#(Agency Use Only) �. <br /> BUSINESS NAME(Same as Facility Nmne or DBA—Doting Business As) 3. <br /> 11NO mwb 6Jt (t ft)20-0, <br /> BUSINESS SITE ADDRESS I- I CITY X04. <br /> 9/d /)rm?64 kq-nF SkT,91-t C�4 <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all rhar WORK AUTHORIZED UNDER PERMIT °flab <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date). <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> INSTALLATION❑ 3.SUMP <br /> 4.UNDER DISPENSERCONTAIINMENT REPLACEMENT <br /> TALLATION OR REPLACEMENT S R DO 61 v z y <br /> 5.OTHER <br /> ES RIPFION OF WORK BEING CERTIFIED: 483c. <br /> Qel-'Veto Sense"'- 7-k 8? {%/� lKlato /y►2 $LQL� 79`/ 3g ' 30�� <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTAL/L�/A�TION/MODIFICATION 4s <br /> CONTRACTOR LICENSE# ICC CERTIFICATION# 481c <br /> 48zb <br /> 9�apgs CC73GU�/ <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 a 'ence with underground storage tanks stem installations. <br /> SIGNA7 OF TANK OR OWNER'S AGENT DATE 4N 1 PHONE 4V- <br /> CER :S� (p' 485- CERIIFIER'S TITLE: 486 <br /> Amts iA Q t Z-17- <br /> NAME OFCRTBFIER'SEMPLOYER( A) 48, CERTIFIER RELATIONSHH'TO TANK OWNER 0B9 <br /> /� ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ��//L C OSS J'r'/�r 4'� ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(122007)-12 vnnw.oaldoa.org <br />