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Apr 20 09 09:33a 209-367-5424 p.2 <br /> 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 4(Agency Use Only) 1, <br /> BUSINESS NAME(Same as Facility Name orDr3.4—Doing BusinessAs) 3. <br /> Cltl 64 SeA%JiC6 - cap,PDA'AfrLdJ <br /> BUSINESS SITE ADDRESS toy. CITY tea. <br /> I I S 144 44-AJ 4-v-D i C4- . <br /> H. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check atl that applvi "tea WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ L TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SU4tP INSTALLATION OR REPLACEMENT J;k Q 0 S-6S 7 7 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> ESCRLPTION OF WORK BEING CERTIFIED: _ 483c. <br /> v f, gagAs <br /> qq6/ '`�fL)9 , ✓f l ooa V Ae--VO14 Pi_'Al P <br /> MI; 010-0 NZ)ZZLdi5Sf 7S,6 CDA X/ #Vs6s <br /> C AJ0 / S40, <br /> M. CONTRACTOR INFORMATION <br /> NANVE OF!CONTRACTOR WHO RFORMED INSTALLATION/MODIFICATION 41'_s. <br /> josov <br /> CONTRACTOR LICENSE# fib. ECC CERTIFICATION# 182` <br /> 6 ` Sur 0a?,v1 I q,6.2, _ v17 <br /> IV. CERTIFICATION <br /> I certify that the information proAded herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requircments set forth in 23 CCR§2715, subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment wns 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 bccn 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 re 'sterefeioal ' r having education and c en°ce ith3underground storage anc k syYstem> installations. <br /> SIGNF TANK NR R OERS AGENT DATE PHONE <br /> 487. <br /> 4 � o3f�o <br /> .F FfF.R'S NAMR{pri.rt) <br /> 485' CERTTFIFR'S TITLE: ass <br /> NAME OF CERTIFIEWS EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> 6L�y T���,Q rS�� �� W3.CONTRACTOR <br /> ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br />