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Feb 04 09 01:41 p Reliable Petroleum 209-845-8953 p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION I MODIFICATION <br />(One form per project) <br />I. FACILITY INFORMATION <br />FACILITY ID (Agent} Use Only) <br />w� rvKn�t roame as P ac'111Y ivame or VBA - Doing Business.4s) <br />i+0,y^y"--5-r L -vx-e- ®i L <br />ESS SITE ADDRESS 10. <br />—5 V �A U-), (f!l 11i ri'i Yom'" C n <br />II. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br />T17PE OF PROJECT (Chea all that aonlvi 4esa. WORK AUTHORIZED UNDER PERMIT 48A <br />❑ 1. TANK INSTALLATION OR REPL.ACB RENT <br />(Number or Dam): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />[13. DINSTALLATION OR REPLACEMENT <br />[1UN <br />4, UNDEE R DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />ig 5. OTHER I <br />1 <br />DESCRIPTION OF WORK BEfNG CERTIFIED: <br />d'et)(atec( t... F' <br />%C� CIYI VP -ed& -L �✓zC>� i L'i'? SU %e s <br />III. CONTRACTOR INFORMATION <br />NAME- OF CONTRACTOR l74I10 PERFORMED INSTALLATION! M651FICATION 492a. <br />�Ctt .bi - <br />CONTRACTOR LICENSE 9 48' <br />ICC CERTIFICATION # <br />IV. CERTIFICATION <br />T 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 installed <br />was. according to applicable <br />voluntary consensus Standards and any manufacturer's written installation instructions. <br />• AlI work Iisted 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 registered rofessionaI engineer havingeducation and a erience with under andry stoa tank system installations. <br />SIGNAT(JjtE OFT 0 ER OR O R'S AGDATE 464• PHONE 411, <br />0 6,z,�,� 1, /0 C/ <br />1 <br />CER T�IFI(E�WS NAME (prim Ass. <br />(P-6 b -e <br />CERTIFIER'S TITLE: {� 436. <br />.. 0. r n (2,-0 <br />012 "yal.0-t vim <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 4s8. <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER ALIT14ORI7ED AGENT OF TANK OWNER <br />UPC1F LIST -C Rev. (12f2007) - I12-v"w.unidocs.org <br />