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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 /> 3. <br /> BUSINESS NAME(sanen FACaRY NAME mVB -r ng Buis A:7 <br /> BUSINESS SITE ADDRESS <br /> 103. CITY tot. <br /> q0 0 W(:-3r LN L,-�c-14fTo.J <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> Oar. WORK AUTHORIZED UNDER PERMIT 493s <br /> TYPE OF PROJECT(Check all that aoolvl <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number.or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT —S tz C)C) ; if&- q q <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5 OTHER 493c <br /> DESCRIP'T'ION OF WORK BEING CERTIFIED: <br /> R�DcI�� Cm�w i c) r— 569� teen(- 6U(-)Cr,- <br /> �ZLI��JT pnJ �A�tL J7�ll/)L <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4szc <br /> ` ICC CERTIFICATION# 482e <br /> CONTRACTOR LICENSE# <br /> Z 5 <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 /> b are 'stered professional en ear havingeducation and ex erience with under s underground story a tank stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE tom. PHONE 48° <br /> CERT 'SN <br /> 4aa CERTIFIER' TITLE: 4ei <br /> (print) <br /> .S t S 1V Z <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 4as. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNERG <br /> OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />