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UNIFIED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> ® (One form per project.) <br /> I. FACILITY` TION 0 C' <br /> FACILITY ID#(Agenry Use Only) e 1 <br /> _ L <br /> BUSINESS NAME(Same ss FAM.17y NAME or DBA-Doing Business As) <br /> r,.. 1. L010 3. <br /> BUSINESS SITE ADDRESS 103• CITY @� <br /> PERMITI S `-ICE ia. <br /> II. INSTALLATION/MODIFICATION PROJECT 1)ES.. PT'ION <br /> TYPE OF PROJECT(Check 453a <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT WORK AUTHORIZED UNDER PERMIT 48X <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br /> [13.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT Q r� <br /> 'OTHER 4 Us <br /> ESCRIPTION OF WORK BEING CERTIFIED: <br /> 453c <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATTON <br /> CONTRACTOR LICENSE# 452b. ICC CERTIFICATION# <br /> &q 452a <br /> 4Sa SSS - Ul <br /> IV.CER • CATJON <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 second <br /> ary acturer's written installation <br /> nstalled nrs <br /> voluntary consensus standards and any manufacc <br /> tent was iording to applicable <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 /> b are 'stered rofessional en neer havin education and ex 'ence with under ound store a tank s stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE <br /> a5a. PHONE 487. <br /> CERTIFIERGO as <br /> 'S.N/AME rent) / /� ( 453 CERTTFdER'S TITLE;, <br /> (l� e-M k/'Y�V 456. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 458 <br /> CERTIFdER'S RELATIONSHIP TO TANK OWNER 459. <br /> � ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> `a U' S 3 S 3.CONTRACTOR [D4.PROPERTY OWNER <br /> S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12!2007) <br />