Laserfiche WebLink
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 /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> VA <br /> BUSINESS SrM ADDRESS 103 BUSINESS SITE CITY 104. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that annly) 483& WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT ��r�;j 6o <br /> ❑ 4.UNDER DISPENSER CONT ENT INSTALLATION OR REPLACEMENT <br /> OTHER --57,9,11 <br /> H <br /> DESCRIFTION OF WhRK BEING CERTIFIED: Q� Cl l v apo- Q Y S�,�� GC J 483a <br /> otw- (l ) goo,- d,7 P;// tv'e'ot-y_ A lK Ca ryes,. 1S /bv.��. •-� <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRAC OR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> r v vrtJ <br /> CONTRACTOR ICENSE# aazb. ICC CERTIFICATION# asz`. <br /> 3oa3�� fJ yJOl077 <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 i registered professional engineer having education and ex erience with underground storage tank system installations. <br /> /D nwtvFR'S AGENT DATE 484. PHONE 487• <br /> SIGNAT� ..T""'""""", <br /> g/-V/lia (7iy <br /> �nxi trtl;R,i6 NAMEgnt)� 485' CERTIFIER'S,TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> p [3"3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> Dlrr ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org Effective 01/17/08 <br />