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Sep 08 lO 11 : 314- Elite IV Contactors 12094 342 ; p. 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM SEP <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION 1 MODIFICATIOlu <br /> (One form per project) ��,.�; � '°a,� <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t- <br /> BUSINESS NAME(Same as FacUlly Narne or DBA—Doing Business&) 3. <br /> BUSINESS SITE ADDRESS I J 103• CITY J� J 104. <br /> �7� '•J L � E'er`GJ'v��v.,R.r l�':ht2... <br /> 11. INSTALLATION INSTALLATION 1 MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aao&) 4834- WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT / <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT �C�C <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4M <br /> III. CONTRACTOR INFORMATION <br /> NAME OCONTRACTOR WHORMED INSTALLATION/MODIFICATION 4874-. <br /> CONTRACQ;LICENSE 4M 1 ICC CERTIFICATON#�5` 48?.e. <br /> Ce <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 professiotal engineer having education and ex erience with underground storage tanks stem installations. <br /> SNAT OF TANK OWNER :OWNER'S AGENT DATE 434. ONE j��„ 487• <br /> — 48 � i 2) <br /> CERTIFIER'S NAME(print CERTIFIER'S CERTIFIER'S TITLE: �G/ ass. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIOAISHIP TO TANK OWNER 489' <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ .OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(1212007)-1/2 www.unidoes.org <br />