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FIED PROGRAM CONSOLIDATED FO <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 />BUSINESS NAME (Same as Facility Name rDBA — Doing Business As) 3. <br />6y10uNr!�y ew-e 76 <br />BUSINESS SITE ADDRESS 9103. <br />CITY 104. <br />/� `` / <br />V© W. (K Cd`4 <br />II. INSTALLATIO / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that apply) 483a <br />WORK AUTHORIZED UNDER PERMIT 4836. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />[1 2. PIPING INSTALLATION OR REPLACEMENT <br />C]3. SUMP INSTALLATION OR REPLACEMENT <br />p� <br />S,e 00 5 7 *3/ <br />❑ 4. UNDER DISP NS R CONTAINMENT INSTALLATION OR REPLACEMENT <br />5. OTHER grcCe <br />ESCRIPTION OF WORK BEING CERTIFIED: 483. <br />/ <br />/-/? Otto Ct� r cc� L y 50 c(t/! t:,-ttCket <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482. <br />191le44 7L NIBS <br />CONTRACTOR LICENSE # a8zb. <br />ICC CERTIFICATION # 48z`. <br />gZr29C <br />523 <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 stem installations. <br />SIGNATURE OF TA K OWNER R OWNER'S AGENT <br />DATE 484.ONE <br />7—S' <br />487. <br />5-19-0 <br />i,6 8 76 --.O <br />CERTIFIER'S NAME (print) 485. <br />Ile <br />CERTIFIER'S TITLE: 486. <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488. <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />❑ L TANK OWNER ❑ 2. TANK OPERATOR <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />��iCCC/// <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.unidoes.org <br />