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1 ` <br /> 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) t' <br /> BUSINESS NAME(s.oPAcany KAMEaDBA-DohsI m) 3• <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aim 493` WORK AUTHORIZED UNDER PERMIT 4936 <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4&k <br /> t o v � Sk.Nso� ��v� Fo4 ��tiE (R�t+, '194380-323 . ysr.�jet_ <br /> was •%WE'D <br /> �� vc Se cz�,o o•�• w•�v► �+o �vuJtwS • S►� 5olti1(a,►�� tow�•t'� �v s�o�. .�u•�u►�PA N��qy <br /> VIAS Qt.4/bt��tt eco viK� 'CfcK���•. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4CL <br /> Qdmqg t v%G <br /> CONTRACTOR LIC SE# 482tL ICC CERTIFICATION# 492` <br /> 220 22 3 —w� <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 'ence with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 187. <br /> \,L 0°1 <br /> CERTIFIER-S NAME(print) 495 CERnmik'S TITLE: <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4U CERTWIER'S RELATIONSHIP TO TANK OWNER 4". <br /> ❑ 1. ANK OWNER ❑ 2.TANK OPERATOR <br /> [3-3.CONTRACTOR C] 4.PROPERTY OWNER <br /> THE AR UTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(1=007) <br />