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UPCF UST$rtification of Installation/Modification Form Instructions (Formerly SWRCB Form C and UPCF Fortu hwfNvrc-c) This Certification form must be submitted upon the completion of installation or upgrading of tanks and/or piping associated with a UST system, Installation or upgrading of multiple tank systems may be addressed on one form. The UST owner or an authorized representative of the owner must complete this form,(Now Numbering of these instructions follows the UPCF data cletrient numbers oil the Certification form.) 1, FACILITY ID NUMBER-This space is for agency use only. 1 BUSINESS NAME -Enter the complete Facility Name. 103. BUSINESS SITE ADDRESS -- Enter the street address of the facility, including building number. if applicable. This address must be the physical location of the facility. Post office box numbers are not acceptable. 104. CITY -Enter the city or unincorporated area in which the facility is located. 482a. NAME: OF CONTRACTOR WHO PERFORMED INSTALLATION / MODWICATION - Enter the name of the contractor who performed the work as registered with the Contractors State License Board(CSI.,B). 482b. CONTRACTOR LICENSE 0 - For the contractor named above, enter the license number assigned by the Contractors State License Board(license information is available online at www,csIb.ca.gov). 482c.c. [CC CERTIFICATION 11 - Enter the International Code Council (ICC) '*UST Instal lation/Retrofitting7' certification number possessed by the contractor. 483a. TYPE OF PROJECT-Check the appropriate box(es)to indicate the type of work performed. Address each system component individually(i.e.. for installation of a complete motor vehicle fueling UST system,check boxes I through 4). 483b. WORK AUTHORIZED UNDER PERMIT`(Number or Date)-Enter the number of the permit issued by the local agency,or if no permit number,the date the permit or project approval was issued for the work being certified. 483c-DESCRIPTION OF WORK BEING CERTIFIED - In the space provided, briefly describe the work performed. Include the number and type of UST systems installed or upgraded and the scope of work, (eg,, "Installation of piping sumps and under dispenser containment., and replacement of product and vapor recovery piping associated with one 12,000 gallon regular unleaded and one 8.000 gallon premium unleaded motor vehicle fuel tank,"). SIGNATURE OF TANK OWNER OR OWNER'S AGENT --The tank owner or an authorized agent of the owner shall sign in the space provided. 'I'llis signature certifies that the signer believes that all the information submitted is true and accurate. 484, DATE CERTIFIED-Enter the date the form was signed, 485. CERTIFIER'S NAME-Enter the full printed name of the person signing the form. 486. CERTIFIER'S TITLE-Enter the title of the person signing the form. 487. PHONE Enter the phone number of the person signing the certification. Include the area code and any extension number. 488. NAME OF CERTIFIER'S EMPLOYER Enter the name(DBA)of the employer of the person signing the form. If the tank owner is an individual,and the owner signs the Certification,note"N/A"(Not Applicable)in this space. 489. CERTIFIER'S RELATIONSHIP TO TANK OWNER - Check the appropriate box to indicate the nature of the relationship between the person signing the forin and the tank owner. RECEIVED AUG 0 4 2014 ENVIRONMENTAL HEALTH DEPARTMENT UNT U14-T-CRes.(1212007)-2!2 t%-Atnmnidamorg