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1�1 <br />1-1 <br />UST Installation - Certificate of Compliance <br />Formerly SWRCB Form C <br />Complete this certification upon installation of an UST and piping. One certification is required for each tank system. This <br />page may be completed by either the UST owner or representative. <br />Refer to 23 CCR 2635 for UST installation and testing requirements. <br />(Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data <br />element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, <br />the Business Section of the Unified Program Data Dictionary.) <br />Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is <br />complete and if any pages are separated. <br />FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which <br />identifies your facility. <br />BUSINESS NAME - Enter the full legal name of the business. <br />476. ADDRESS - Enter the street address where the tank is located. This is to assist the tank inspector in locating the <br />tank. <br />477. TANK ID NUMBER - Enter the tank ID number assigned by the owner. This is a unique number used to identify the <br />tank. It may be assigned by the owner or by the CUPA. This is the same as item 432 as found on the UST Tank <br />Page 1. <br />478. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER - Check if the tank installer provided <br />evidence of being trained and certified by the tank and piping manufacturer. <br />479. REGISTERED ENGINEER INSPECTION - Check if the installation has been inspected and certified by a registered <br />professional engineer, if necessary. <br />480. UNIFIED PROGRAM AGENCY APPROVAL - Check if the installation has been inspected and approved by the <br />Unified Program agency. <br />481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check if all work listed on the manufacturea installation <br />checklist was completed. <br />482. CONTRACTORSOSTATE LICENSE BOARD CERTIFICATION OR LICENSE - Check if the installer has provided <br />proof of CSLB certification or licensing. <br />483. INSTALLATION DESCRIPTION - Check if the UST system was installed according to applicable voluntary <br />consensus standards and any manufacturers written installation instructions. Describe the installation in the <br />space provided. Clarify the type and the extent of work completed at the facility, such as installation of dispenser <br />containment, replacement of piping, or installation of turbine sumps. <br />SIGNATURE OF TANK OWNER/AGENT - The tank owner or agent of the owner shall sign in the space provided. <br />This signature certifies that the signer believes that all the information submitted is true and accurate. <br />484. DATE CERTIFIED - Enter the date that the page was signed. <br />485. TANK OWNER/AGENT NAME - Enter the full printed name of the person signing the page. <br />486. TANK OWNER/AGENT TITLE - Enter the title of the person signing the page. <br />UPCF (1/99 revised) 15 Formerly SWRCB Form C <br />