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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) -7 � d <br /> BUSINESS NAME(Same as FacilityName or DBA—Doing Business As) <br /> �c/(�ars�l <br /> BUSINESS SITE ADDRESS / 103 BUSINESS SITE CITY 104 <br /> - :1242L-2arri( 4-L-� <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aoolvl a'``' 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 6 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 1 asap. <br /> 8�raj�o 4�e G-iok Tes �eol $-S N�gtn Lt�ur� Sev\5or- W/ <br /> H-D 14.5pQ +o,- . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION a'`-a <br /> \ <br /> CONTRACTOR LICENSE# 482b. I ICC CERTIFICATION# aS'_c. <br /> '? 0 5 <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 /> SIGN A RE OF TA OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> ! l <br /> CERTIFIER'S NAME(print) 485. CERTIFIER'S TITLE: ase. <br /> Ti <br /> E OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER ase. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> Oill-OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org Effective 01/17/08 <br />