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UNIFIED PROGRAM CONSOLIDATED FORM <br /> • UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) r, <br /> BU INESS NAME(Sameas Facility Name or DBA-Do'g Business As) 3 <br /> Mf <br /> ClA <br /> BUSINESS SITE ADD SS 103. CI 104. <br /> Ej,-/ rwntw C11 <br /> vv►+- <br /> II. STALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that annlvl 483& WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT Wf,3�-YT6 <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DE CRIPTION OF WORK BEING CERTIFIED: 483c. <br /> n �\avkm o� G\ecu Au5Pcl^ce�rs Lo I?X&vo <br /> III. CONTRACTOR INFORMATION <br /> NAM OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> i <br /> CONTRACTOR LICENSE#, A <br /> 482b. ICC CERTIFICATION# 482`. <br /> U2 <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 experience with underground storage tank system installations. <br /> SIGNATURE O ER OR OWNER'S AGENT DATE 484, PHONE 487. <br /> T R'S NAME(pnn � �r�485' CERTIFIER'S TITLE: 486, <br /> NA,VE OF Iil11CIFIi 1' EMP OYER(DBA488. CERTIONSHIP� TANK OPERATOR ANK OWNER 489 <br /> ❑ 1.TANK OWNER <br /> • 2�a.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 />