Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />_ <br />_ <br />1. <br />BUSINESS NAME (Same as FacilityName or DBA — Doing Business As) 3. <br />BUSINESS SITE ADDRESS/ % 103• <br />CITY 104. <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that annlvl 483& <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />S.OTHER ,T. S:A!9 � <br />DESCRIPTION OF WORK BEING ER IFIED: 483c. <br />/f?L✓ ®� <br />h 14H� <br />, <br />III. CONTRACTOR INTO TION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482& <br />CONTRACTOR LICENSEE # 482b. <br />aszc <br />ICC CERTIFICATION # <br />7V2 <br />)' <br />/ <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, and that the foiiowing 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 are 'stared professional engineer having education and ex erience with under ound store a tanks stem installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 4> <br />(� <br />487. <br />/PHONE <br />CERTIFIER'S NAME (print) 485' <br />CERTIFIER'S TITLE: 486' <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488' <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UP'CF UST -C Rev. (12/2007) -1/2 www.unidoes.org <br />