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'MFIED PROGRAM CONSOLIDATED FOR4W <br />UNDERGROUND STORAGETANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />I <br />BUSINESS NAME (SameasR htyName orDBA — Doing Business As) 3. <br />ce(cc <br />BUSINESS SITE ADDRESS 103. <br />CITY 104, <br />Wz 6a2iem- <br />1 ;�&� <br />11. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that 483a. <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />F1 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />El 2. PIPING INSTALLATION OR REPLACEMENT <br />[71 3. SUMP INSTALLATION OR REPLACEMENT <br />[1 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />JR- 5. OTHER <br />DESCRIPTION OF WORK BEING C?7D: 483c. <br />M. CONTRACTOR INFORMATION <br />WHO PE 0 INrATION /MODIFICATION 482a. <br />!NTFTNTRACTOR <br />CONTRACTOR LICENSE # 4szb.ICC <br />Q <br />CERTIFICATION # 4820. <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 instal ion h been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />instal <br />,Ay7a reg;*� <br />fessional engineer having education and ex rience with underground storage tank system installations. <br />R OR OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />6 06 36 <br />eo T TA R 1 6 NA E 485. <br />CERTIFIER'S TITLE: 486. <br />"z <br />3F CERTIFIER'S EMPLOYER (DBA) 488, <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />7V-e�ekll- <br />0 1. TANK OWNER 0 2. TANK OPERATOR <br />pbl- CONTRACTOR n 4. PROPERTY OWNER <br />rl 5 OTHF.R AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.unidoes.org <br />