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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION /!�EhMED <br />(One form per project) <br />;' I FACILITY INFO TIONLos <br />FACILITY ID # (Agencv Use Only) <br />I <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. <br />JOAQUIN COUNTY <br />SM <br />BUSINESS SITE ADDRESS 103• CITY p 104 <br />IC. TIVSTALLATION I MODWICx�TI4N PROJECT DESC � P. <br />TYPE OF PROJECT (Citeckall that a Iv 4830' <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANX INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMEA"I' <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 4asc. <br />'V7 (,-x>2 t- . <br />t--t-eco' r,Sc c n Ad 15L- p <br />` ,,1 c t�-10,. 4 -es �- .C,,, 44-� 4'10 s P <br />ri's er- <br />• ` -e> oLe- f r L'' S•i `k -.`J <br />.. nL CONTRACTOR NFORNLATION <br />NAME OF CONTRWHO PERFORMED INSTALLATION ! MODIFICATiON 482. <br />iACTOR <br />�.i -e— L V C Ira Cc.. C 1 01rS - <br />CONTRACTOR LICENSE # 4°26' <br />00 9G7 <br />ICC CERTIFICATION ®� � � 4az`. <br />iV CERTITICATJON <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 />• AlI 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 re 'stered professional engineer having education and ex erience with underground stora a tank system installations. <br />SIG TURE OF TANK WNER OR OWNER'S AGENT <br />DATEQ NE 487. <br />.- <br />3 <br />4z3 <br />485' <br />,CGT/IF�IEER'S N/A//M/E (print)( <br />CEiTIFIE 'S TITLE: 480. <br />_te <br />O <br />kx <br />NAME OFC IFIER'S EMPLOYER (DBA) 4819. <br />a _ <br />CERTIFIERSRELATIONSHIP TO TANK OWNER 4av' <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />OF TANK OWNER <br />tC215. <br />OTHER AUTHORIZL•D AGENT <br />UPCF UST -C Rev. (1212007) -112 www.unidvcsorg <br />T -d 24C9 T 94602 ou I sjogoej4uo0 ^I OI T 13 eS2 z BO 20 62 unr <br />