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EC Y <br /> JUIV 2 0 2008 <br /> UNIFIED <br /> UND ROGRAM CONSOLATED UNDERGROUND .STORAGE TANK ORM SAS�O`IGII,�)' <br /> CERTIFICATION OF INSTALLATION/ MODIFICTt-10N-,.,-,, e1, <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY 1D 5(Agency Use Only) t;. <br /> BUSINESS NAME(Same as Faciliry Name or DBA—Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY lay. <br /> IL. INSTALLATION/.MODIFICATION:PROJECT DESCRIPTION: <br /> TYPE OF PROJECT(Check all that angly) 483e. WORK AUTHORIZED UNDER PERMIT 433b. <br /> ❑ 1.TANK rNISTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT \( �� 'N/0 <br /> �f n <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT \J J(,I � <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: :s3 <br /> Caeca ., ,��s �� �� ''�` �. <br /> �� 1< <br /> -1 C/1 <br /> III: CONTRACTOR INFORMATION <br /> NAME-OFC R A O "WHOP STAL;,ATION/MODIFICATION <br /> CONTRACTOR 1 NSE$ 432b' ICC CERTIFICATION# 48'`' <br /> c� C - z �- &313L2, 811 <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 re isteprofessional engineer having education and ex erience with underground storage tank stem installations. <br /> SIGNATURE OF NIC OWNER OR OWNER'S AGENT DATE 464• PHONE 487. <br /> CERTIFIE49,bAME(print) 4ss. CERTIF S TITLE: 1 486• <br /> tr`(f C. <br /> NAXIE OF CERTIFIER'S E LOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. <br /> � J ! <br /> n C31.TANK OWNER ❑ 2.TANK OPERATOR <br /> � L�r7 ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(I 2J2007)-1/2 www.unidocs.ure <br /> T .d Zt1E9 T 9i160Z OUI sJ040eJ4UO3 n I a-4113 e i E :60 ZO Oz U11C <br />