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Nov 19 09 08:31p Reliable PetroleumA 209-845-8953 p.2 <br /> UNMED PROGRAM CONSOLIDATED FORM <br /> F- UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLA'T'ION I MODIFICA'T'ION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(A,gency�tura Only) <br /> t. <br /> BUSINESS NAME(Salm as Facifhy Frame or DBA—Doing Busfne s.44 <br /> t- F-UeL, <br /> BUS11N SITE ADDRESS <br /> 10-x• CITY <br /> -T s-Ca cou.n fr- c Lu-,1b 1 v c tom. <br /> . <br /> II. INSTALLATION f MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check aff that aanf RIZED UNDER PERMIT <br /> Q I.TANK INSTALLATION OR REPLACEMENT WORK AUTHO =sib. <br /> Q 2.PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br /> D 3.SUMP INSTALLATION OR REPLACEMENT <br /> Q 4.UNDER DISPENSER COE;T ttINMENTINST.4LLAT10N OR REPLACEMENT �-S <br /> JZ,S.OTHER <br /> DES RIPTION OF WORK BEING CERTIFIED: <br /> III. CONTRACTOR INFORMATION <br /> NAM OF 147RACTORvti+ OpS tM INSTALLATION 1 4 FtCATiO\i <br /> 7 <br /> CONTRACTOR LICENSE# 4sa,. <br /> r t ICC CERTIFICATIO-IN 4, 4 rc <br /> IV. CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the f0110wing 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%Titten installation instructions. <br /> • All work Iisted in the manafacturer'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 /> a re -stored professional en ineer having education and a -once with underground storage tank system installations. <br /> SfGNA SIRE OF T N' NER OR O 7VER'S A r DATE 4s4. <br /> PHONli 4E7, <br /> IF ER'S NA (pAnt) <ss. CERTIFIER'S <br /> LE:TIT <br /> / n 486. <br /> NAME.OF CERTIFIER,S EMPLOYER(DBA) 4as CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> asp. <br /> 0 1.TANK OWNER Q 2.TANK OPERATOR <br /> V�✓ % f l �i�� J / Ltf 3.CONTRACTOR Q 4.PROPERTY OWNER <br /> Q S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rcv.(1202007)-1/2 www.unidocs.org <br />