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Feb 09 09 08:48a Reliable Petroleum 209-845-8953 p,2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION I MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID 0(Agency Use Only) <br /> - I I T-7 <br /> BUSINESS NAME(Sarre as Facility Name or DBA—Doing Businew As) 3. <br /> a►n Strecf- Acv <br /> BUSINESS SITE-ADDRESS "3. CITY 104. <br /> loo S, M06 A s t" . M ante cck- <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION ! <br /> TYPE OF PROJECT(Cireckall that aooh) 4838 WORK AUTHORIZED UNDER PERMIT 483 . <br /> I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> [1 4. <br /> C 1_ j„G <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT J tf! to t <br /> S.OTHER <br /> DESCRIPTION OF WORK BENG CERTIFIED: 413c. <br /> 1 <br /> I + <br /> .�. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF COIFTRACTOR WI 10 PERFORMED INSTALLATION/MODI RCATI01 <br /> ke,116Lb1-e- cIrdl e"wi Ser v'C e3 -1h6 , <br /> CONTRACTOR LICENSE 9 492b I ICC CERTIFICATION 4 4120. <br /> ? ? 3� 0 � sas���- UVo-u-L <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 r'ence with underground storage tanks stem installations. <br /> S NA U 2 OF TANK05IR OR OWNER'S GEN DATE 484• 1 PHONE 487 <br /> L2�: <br /> y c�G (AI ) may- %336 <br /> may- %336336 <br /> NAME(print) 48S CERTIFIER'S TITLE: 416 <br /> Co VJ-,rG C+o r <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 413. CERTTFIER'S RELATIONSHIP TO TANK OWNER 439 <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR. <br /> L)4 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5-OTHER.AUTHORI7ED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(1212007)-1/2 wwNv.unidocs.org <br />