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AAL Alk <br /> IFIED 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) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3' <br /> BUSINESS SITE ADDRESS 103' 1 CITY IN. <br /> YOYO U/EST <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that cooly) 483e. WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 0'2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 5Xpps-7 X30 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT / <br /> [1 5. <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483.7 <br /> STz-ez LCX lfvSE IV # Z A�-Vro✓cc-w <br /> mbc . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALL�A�T,,I,O/)N/MODIFICATION 48U <br /> CONTRACTOR LICENSE# 4826.• ICC CERTIFICATION# 4820. <br /> 4HLZZ s25-z -u <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 aregistered professional engineer having education and ex rience with underground storage tanks stem installations. <br /> SI TUREOFTA O ER OR OWNEYUAR'S AGENT DATE 484. PHONE 487. <br /> Je <br /> CERTIFIE NAME ) 485" CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER's RELATIONSHIP TO TANK OWNER 469. <br /> V „( cn n�q ❑ 1,.TANK OWNER ❑ 2.TANK OPERATOR <br /> r/¢— Er3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12!200')-1/2 w .uuidoea.org <br />