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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) 1 <br /> BUSINESS NAME(Same as Faciliry Name or DBA—Doing Business As) 3. <br /> eG�l <br /> BUSINESS SITE ADDRESS 103 BUSINESS SITE CITY loa. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoply) asla WORK AUTHORIZED UNDER PERMIT as5t1 <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (dumber or Date): <br /> i <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT q� <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> Z 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483. <br /> 911BJIo Cold 5+of-� MC) -1for Cori t'4iCCA-+ton. <br /> L- 16 �IecJ� <br /> IIM Re3oL8 filled to 5k-+ Down <br /> C( 0( 11 o Rep 14c.er-k t_- tS 504 te.K SO r <br /> Ize-ptaceel <br /> Tesfieck wlt+% E-14D aVV-k tSZ5a-3 P*A&Q-k <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION asz� <br /> CONTRACTOR LICENSE# 49 y ICC CERTIFICATION# 482c <br /> 3 137 f3ot62 T 83783 <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 storage tanks stem installations. <br /> SIGNATU OF- ANK W'NEROROWNER'SAGENT DATE 494- 1 PHONE as3. <br /> (20.1 )4-74-brby$ <br /> CERTIFIE 'S NAME(print) a85' CERTIFIER'S TITLE: a85. <br /> -tG.V r f if c. 5 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 463' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ I,TANK OWNER ❑ 2.TANK OPERATOR <br /> >' `PG C ❑ 3.CONTRACTOR EJ- 4.PROPERTY OWNER <br /> G� [ 'OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(11/2007)-1/2 www.unidocs.org Effective 01/17/08 <br />