Laserfiche WebLink
Jul.08.2011 08:39 AM <br />1, VA <br />0 10 <br />PAGE. 2/ 2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION OiDIFICATION <br />cone farm M prgjw.) <br />1. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) � <br />BUSINESS NAM(.%nieasFACiLITYNAA&eri>nA—Duinu&ai mAs) 3. <br />BUSINESS SITH Ann S Io: <br />crry I04. <br />s <br />—L <br />If. INSfrALLATION / MODIFICATION PROJEC DESCRIPTION <br />TYPE OF PROIFC.T (Chock a_ftjnQD1Y) 483a. <br />C] 1. TANK INS'I'ALI.ATION OR REPLACL-MEN'I' <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />(Number or i�tey `% — 1 — <br />❑ 2. PIPING INSTALLATION OR RE -PLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CO TAINMEN I INSS'I ALI,ATION OR RCFLACEmLN'r <br />'s 4 6-6 <br />OTHER <br />DeSC:RIPTIONOF WORK BEING CER'[1FIFr); 4830 <br />(',.� 1e1.Q, ►n,, ^�v d L G� X53 L (-k- <br />C4>)-Jt— <br />4>) -JF x:..15 <br />(,- <br />1111. CONTRACTOR INFORMATION <br />NA OF CONTRACTOR WIIO PERFORMeD INSTALLATION / MODIF 'ATION 482". <br />CS +- � CPJV✓X WA C( <br />CONTRACTOR LICENSE # �`''"b <br />ICC CERTIFICATION # 4V -c. <br />7— <br />TV. CERTIFICA'T'ION <br />1, certM 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. §271 S, 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 store a tank s stem installations_ <br />SIONATLJRB OF TANK OWNER ()R OWNF,R'S AQFNT <br />DATF. 484. <br />PHONE. 487. <br />1 <br />IL rlFIER'S N ME (print) 48s <br />Ck 01FIEWS Tri, ': <br />/ C <br />NAME ( CERTIFILR'S Ir OY ' (DBA) 4RR <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 4R9 <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />E:913. CONTRACTOR ❑ 4, PROPPRTY OWNER <br />❑ S. OTHER A(ITHORIZRF) AGRNI' OF TANK owNFR <br />UPC7 UST -C -'1/2 ' <br />Rev. (.1 2/2007) <br />