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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) <br /> BUSINESS NAME(S4 n FACILITY NAME m DBA-Nmg Bmn As) 7. <br /> BUSINESS SITE ADDRESS 103 CITY <br /> S . l-00tSE &VE LN7V! 20 <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that a»nivl 4B3i WORK AUTHORIZED UNDER PERMIT <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): �/ <br /> El 2,PIPING INSTALLATION OR REPLACEMENT IN�'o v�iT y �44L) <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED 49R <br /> Remove existing straight droptubes and replace with flapper style droptubes and remove ball-floats from all USTs. <br /> REC; �` <br /> w w � <br /> DEC P 5 2018 <br /> ENVtRONMEN M SALT <br /> 0EPART <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4W. <br /> Getter-Ryan Inc <br /> CONTRACTOR LICENSE# 4826 ICC CERTIFICATION# 4M. <br /> 220793 1 e0(-7-25-7 <br /> IV. <br /> 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 storage tank system installations. <br /> SIGNATVRE OF TANK OWNFER OR OWNER'S AGENT DATE 494 1 PHONE 487 <br /> 11�Zt(f8 916 ) 851-1830 <br /> C T IER'S NAME(print) 485 CERTIFIER'S TITLE: 486 I <br /> Michael Carruth Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> Gettler-Ryan Inc ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> l9 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(1212007) <br />