COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

Home Browse Search

� 1lr= UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION/MODIFICATION � Ll I` IP'neformperproject.). ; I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILM NAME or DBA—Doing Business As) 3 11f e, BUSINESS SITE ADDRESS im• CITY 104 l : II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that=lvl 483a WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT ❑ 54.UNDER.OTHER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT12 S DESCRIPTION OF WORK BEING CERTIFIED: Me rz Lm i III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO/PERFORMED INSTALL//ATION/MODIFICATION asza CA .*eftjr5CONTRACTOR LIC NSE# 4826. ICC CERTIFICATION# 482e. :,2 U IV.CERTIFICATION I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. • All work listed in the manufacturer's installation checklist has been completed. • The installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified by a registered professional engineer havin education and ex erience with under ound stora a tank system installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494PHONE 487 ii t CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. C ` V NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'A RELATIONSHIP TO TANK OWNER 489. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR .CONTRACTOR ❑ 4.PROPERTY OWNER ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST-C-1/2 Rev.(12/2007) I