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01/05/2010 10:00 FAX 916 371 2380 BZ SERVICE STATION <br />0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />► ! ► !, <br />CERTIFICATION rINSTALLATION MODIFICATION <br />per project) <br />1. ]FACILITY INFORmATION <br />■ EMrwWO1 <br />oUWNZ> bb NAME (Same as Fad Illy Name or DBA — <br />f'OOA J. % .re ► erg <br />Ills- W. Lea r Le <br />H. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PmEf: r (Ckeck a drat an w 4e3a WORK AUTHORIZED UNDER PERMIT <br />❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />0 2. PIPING INSTAUX171ON OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />S. OTHER <br />DESCRIPTION OF WORK BEING CERTIr'IED, <br />Ae P(Ar-e., -4..D 2-000 1 c,+k De--te-cxer— i^j F7 nojlc. <br />DO' 39 pk, E "k Tea'T 'Tesrea +� C3004, <br />III. CONTRACTOR INFORMATION <br />NAME OI: CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATf ON <br />CONTRACTOR LICENSE /# *' ICC CERTIFICATION # <br />/3r 257a.f I. <br />IV. CERTIFICATION <br />I cerdfy 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 />• 'Tule underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and ally 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 />b a istercd Professional en ineer havin education and experience with under ound store o tank system installations, <br />SIGNATW O. TANK OWNER OR OWNERS AGENT <br />CF.RTIFIER'S NAME (print) <br />NAMF. OF CERTIFIER, S EMPLOYER (DCPA) <br />2.2 . /f+ 14 t `AJ t- <br />/ -Yrfa 1(9/6) f <br />CERTIFIER'S TITLE. <br />Service. "rec-k <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />1. TANK OWNER ❑ 2. TANK OPLRATOR <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />Q 5. OTHER AUTHORIZED AGENT OF TANK OWNRR <br />UPCF UST -C Rev. (I V2oo7)_ 1/2 vrtvw.raklocr.org <br />