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Nov. 4. 2013 3:53PM No. P. UPCF UST Certification of bstallakion/Modification Form Instructions NOV 04 2013 (Formerly SWRCB Form C and UPCF Form hwfwrc-e) ENVIRONMENTAL HEALTH DEPARTMENT 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.(Note. Numbering ofthese instructions follows the UPCF data element numbers on the Certification form.) 1. FACILITY 11)NUMBER—'This space is for agency use only, 3. 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 CONMUCTOR WHO PERFORMED INSTALLATION I MODIFICATION—Enter the name of the contractor who performed the work as registered with the Contractors State License Board(CSLB). 492b. CONTRACTOR LICENSE#—For the contractor named above, enter the license number assigned by the Contractors State License Board(license information is available online at M3DXcslb.ca2. ov 482c. ICC CERTIFICATION#—Enter the International Code Council(ICC)"UST installation/Retrofitting"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 perndt or project approval was issued for the work being certified. 483c..DESCRIPTION OF WORK MING 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(e,g.,'Installation of piping sumps and under dispenser containment and replaoement 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 OWNEWS AGENT—The tank owner or an authorized agent of the owner shall sign in the space provided. This 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. 497. 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 form and the tank owner. UPCP UST-C Rev.(1212007)-W