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-UNIED PROGRAM CONSOLIODATED FORM <br />um)ERGRoUND STORAGE TANK <br />CERTIFICATION F INSTALLATION / MODIFICATION <br />(One form per project) <br />I. FACILITY MORMATION <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME (Sane as Facility Mame or DBA — Doing Business As) <br />BUSINESS SITE ADD S 103• <br />i <br />CITY 104. <br />IL INSTALLATION 1 MODIFICATION PROJECT DESCRIMON <br />TYPE OF PROJECT (Check all that apply) 483a <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT*"� <br />(Number or Date): <br />579 <br />3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />S. OTHER <br />DESCRIPTION OF WORK BfEING CERTIFIED: a83c. <br />F/9 _'> V r> ctc <br />Iii. CONTRACTOR O TION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 4828: <br />CONTRACTOR LICENSE # 4sac. <br />ICC CERTIFICAT/ION # <br />/ <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 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 Mfessional engineer having education and ex encs with underground store e system installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 494• <br />PHONE 487. <br />l J <br />CERTIFIER'S NAME (print) 485. <br />486, <br />CERTIFIE 'S TITLE: <br />NAME OF CERTIFIER'S EMPLOY (DBA) 488. <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />JR 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />�j <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) - U2 I www.unidoes.org <br />