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N <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUNDSTORAGETANK <br />CERTIFICATION OF Or <br />•,, LL 1clle *` <br />FACILITY ID # (Agemy Use OnJv) <br />3. <br />BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Busiorss .As) <br />Q v r �K k57L �P M;f-4 7- loa. <br />BUSINESS SITE ADDRESS C�I^TY <br />II <br />A.) <br />Ih INSTALLr',ThON I MODIFICATION PROJEICT.DESCRIPTION <br />asae. <br />TYPE OF PROJECT (Check all that anDly) WOR& AUTHORIZED UNDER PERMIT <br />❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT .fR <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ . UNDER DISPENSER CONT.ANMEN'r INSTALLATION OR REPLACEMENT <br />5. OTHER 4s9c <br />DESCRIPTION OF !PORK BEING CERRTIFIED: t4J/J�,T ®S O) <br />s y�.� � V V <br />III.: CONT 2A.CTOR rgFO AVON <br />4su. <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION IMODIFICATION <br />io A��� <br />482a <br />4"TCC <br />CONTRACTOR LICENSE <br />CERTIFICATION # <br />® <br />IV. CERTIFICATION <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 />• 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 pEqfessional engineer havjEg education and ex erience with unde and Stora a tank system installations. <br />48'' <br />SIGNAT F TANK OWNER OR OWNER'S AGENT DATE 484. PHONE <br />0W (v �) G3�'� 7 <br />486 <br />485 C FiER'S TITL <br />CERTIFIER'S NAME (print) <br />jes:$-91�9- RUA46,v <br />41r489, <br />DAME OF CERTIFIER'S EMPLOYER (DBA) RELATIONSHIP TO TANK OWNER as9. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />J GK3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C - V2 <br />Rev. (1212007) <br />Z'd t Zt,9-L9£-60Z %6:01 60 0£ oaa <br />