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UNIFIED PROGRAM CONSOLIDATED FORM <br /> riN0 8 2009 UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> P. G'l (One form per project.) <br /> PERIfiF/SERVICES 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as FACURY NAME or DHA—Doing Business As) 3 <br /> 0S A Ges; Si-cl-6 o1 <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> LtL(% W K:0A(--C(A4_&Lj_ Lt,, Locu <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a 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 �-/�Q/ O q <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> [ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483; <br /> real c:_cz t,+_7c,-Lf- c( U PL( 4` - L-D D o uA 4 TLcALLc(- 4a..4, <br /> II1. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> SesJ �JcCe_ Sf'C Cwt S $�—QGIiS kC. <br /> CONTRACTOR LICENSE# aezn. ICC CERTIFICATION# <br /> 482c. <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 Stora a tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 1 PHONE 487, <br /> CERTIFIER'S NAME(print) _ 485 CERTIFIER'S TITLE: 486. <br /> KP(RT( we <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIERI RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> `"u'" C .C,�YlCEk 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> CrQ vl LLLSA <br /> , LL ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(128007) <br />