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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1. <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. <br /> PG � r- <br /> BUSINESS SITE ADDRESS 103. BUSINESS SITE CITY IN. <br /> �f 0 y0 WEST L/�NL' �5T-XKM^/ G' <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that arm 483. WORK AUTHORIZED UNDER PERMIT 4835. <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT3.SUMP <br /> F14.UNDER DISPENSER REPLACEMENTATION OR <br /> SER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ta 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Rf?LN-t1) FaYl3C)UT FDt2 �Z#,sTfz DIC- L/Nt 14ND tESTED <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482' <br /> Ge4Her RIAYN <br /> CONTRACTOR LICENSE# 1 4821 ICC CERTIFICATION# 482, <br /> 22o743 Z5'Zol D -ur <br /> IV. CERTIFICATION 4 <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 /> bv a registered zrofessional engineer having education and ex erience with underground storage tanks stem installations. <br /> S[ ATU OF TAN ROWNER'S AGENT DATE 484. PHONE 481. <br /> loltIIIID 237-8 z <br /> CERTIF R'S NAME(print) 4B5. CERTIFIER'S TITLE: 485. <br /> RvaN Mx7viEwS EC/-ln(/C/ <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) M. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> El L TANK OWNER [12.TANK OPERATOR <br /> n/� <br /> �,3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.uuidocs.org Effective 01/17/08 <br />