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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form;•rr rwjcct) <br /> 1. FACILITY INFORMATION <br /> FACILITY ID N(Agency Use Only) <br /> BUS IN ESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> 3. <br /> BUSINESS SITE ADDRESS 1u3 CITY 3 <br /> BIZ S �I J C OY1 <br /> 11. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 383a WORK.AUTHORIZE'D UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT IN Urnber or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT S R C) <br /> ❑ 4 UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5 OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED <br /> 4830 <br /> irerf rry cl sola S�z� r cincl re-prc c�mmr d <br /> pevRr- E Ut P`� 'rade recd u 1're►ane <br /> 111. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 48, <br /> PSP <br /> CONTRACTOR LICENSE N 3826 ICC CERTIFIC'ATTON a 48k. <br /> 2 '7 <br /> IV.CERTIFICATION <br /> 1 certify that the information provided herein is true,accurate,and that the following conditions h;n a been satislic(:: <br /> • The installer has met the requirements set forth in 23 CCR§271 ,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to ;Ipplicable <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 ;,!,d certified <br /> by a registered professional engineer havingeducation and ex erience with underground storage tank system inst:l":r is. <br /> SIG TU OF TANK OWNER OR OWNER'S AGENT DATE +8+ I'I Ic hNL 48' <br /> (X)9 )cN 3 3oc <br /> CERTIFIER'S NAME(print) 385 CERTIFIER'S TITLE +8a <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 388 CERTIFIER'S RELATIONSHIP TO TANK()%VNI R 489 <br /> ❑ I.TANK OWNER ❑ 2.TANk OPERATOR <br /> V 9 3.CONTRACTOR ❑ -1.PROf'I RTY OWNLI, <br /> ❑ i.OTHER AUTHORIZED AGENTOF TANK OWNER <br /> UPCF UST-C-1/2 <br /> R .112/2007) <br />