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• 93/23/2009 05:03 661634g'z33 KERN CONSTRUCT PAGE 03/07 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One ram Per pmjftt.) <br /> I. FACD. rYINFORMATION <br /> FACILITY To B(Agarcy Use only) <br /> BUS S AME( EAC hAMa mD - ga ° A.1 I.. <br /> LV 1. <br /> BU EVESS SIT RE tN C <br /> ITY <br /> Ix. INS ALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(check lVl that ewlv7 40. WORK ACri'IJORIZED UNDER PERMIT Base. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Nmnher or Gate): <br /> Ll2.13MNOINSTAt1ATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT ll <br /> S.OTHER <br /> DESCRIPTION OF WORK Bry0E[ CER /IFD; <br /> ---h„ —w. t!/QIX'11 � C('� �l '�!L�1 �I•t(k�� l L� 3�� �Gy1�/�r; <br /> M. CONTRACTORINFORMATION <br /> NAM£OF CONTg�erOR 0 PE��RAgD INSTgL[.AT[ON/MO TION �u <br /> CONTRACTOR LICENSE p '_�-(I'^(/`,(,.,-1/`11u,.V\ °M12^' ICC CERTIFICATTON N °eze <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 sat forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • <br /> The underground storage tank, any primary piping, and any secondary containment was installed according tri applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> All work listed in the manufactarer'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 /> a re 'steted profeasional engineer havin I education and ex 'cnee with under round story tanks stem installations. <br /> ONATUREO TANK OWNER WNER'S AGENT DATE °q°, /PHONE 1 v 487 <br /> C TIPtER�tf ` ntI °� CER P Trr <br /> } 61, <br /> AME OF CERTIFIER'S EMPLOYER(DBA) °Bg CER R'S RELATIONSHIP TO TANK OWNER 499, <br /> J� �,A <br /> "�,, ❑ 1.TANK OWNER Q 2.TANK OPERATOR <br /> V 1, S i' vLC' /- I \ L v `G I-CONTR5 OTHER ACUTHORIZFD AGENT OCTOR C3 4. F OWNER <br /> UPCF UST-C-1/E <br /> Rev.(1 2/21111 7) <br />