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�EI <br /> Adak Mftk <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> E: <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 /> 1. <br /> BUSINESS NAME(Same as FACB.n'Y NAMEor DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS 5 103. CITY ioa. <br /> ii LU LI,'-kl�i- St. C A- <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDDly) 483a WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): � <br /> [1t (s' � <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT V rA I <br /> C9-5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 483c <br /> Vr <br /> eV LaAe, <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> CONTRACTOR LICENSE# 4826' ICC CERTIFICATION# 482c <br /> S3( I S3 (-- u-C <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 a registered professional engineer having education and ex erience with underground storage tank s stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484PHONE 487 <br /> tj- If/Waw (-IAV af35403F <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> e ❑ 1.TANK OWNER El 2.TANK OPERATOR <br /> *.t ' A SvStkag, .l L;_ �3.CONTRACTOR El 4.PROPERTY OWNER <br /> i ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />