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Ah <br />Ak <br />low '07 <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) <br />1. <br />BUSINESS NAME (Same as Facility Name or DBA — Doing Business As) 3. <br />LIQ <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />(e-'- I'U�J C- <br />II. INSTALLATION / M DIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that avnly) 483a. <br />WORK AUTHORIZED UNDER PERMIT 4831. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5. OTHER <br />CJ <br />DESCRIPTION OF WORK BEING CERTIFIED: <br />�1 �483c. <br />C� <br />III. CONTRACTOR INFORMATION <br />NAME WHO PERFORMED INSTALLATION // MODIFICATIONy�� 482& <br />�O�FFCCONTRACTOR <br />CONTRACTOR LICENSE # 4821. <br />ICC CERTIFICATION # 482c_ <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 rience with underground storage tank system installations. <br />SIG TUBE OF TANK OWN R O OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />C-/ 16 /o <br />61 <br />R IFIER'S NAME (printp 485' <br />R FIER'S IT 486. <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488. <br />CERTIFIER'S RELATIONSHIP O TANK OWNER 489. <br />1. TANK OWNER ❑ 2. TANK OPERATOR <br />-+ <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.unidocs.org <br />