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UST Installation - Certificate of Compliance Form Instructions <br />(Formerly SWRCB Form C) <br />This Certification form must be submitted upon the completion of installation or upgrading of tanks and/or piping associated with a <br />UST system. A separate form is required for each tank or, in the case of compartmentalized tanks, tank compartment. This form must <br />be completed by the UST owner or an authorized representative of the owner. Please number all pages of your submittal. (Note: <br />Numbering of these instructions follows the UPCF data element numbers on the Certification form.) <br />FACILITY ID NUMBER - This space is for agency use only. <br />BUSINESS NAME - Enter the complete Facility Name. <br />476. ADDRESS - Enter the street address where the tank is located. <br />477. TANK ID NUMBER - If the UST owner has assigned an in-house tank ID number to this tank, enter that number in this space. <br />This is the same as item 432 on the UPCF UST - Tank Page 1. <br />478. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER - Check this box to certify that the installer of this <br />tank system has been trained and certified by the tank and piping equipment manufacturer(s). <br />479. REGISTERED ENGINEER INSPECTION - Check this box if the installation was inspected and certified by a registered <br />professional engineer (PE). <br />480. UNIFIED PROGRAM AGENCY INSPECTION - Check this box if the installation was inspected and approved by the Certified <br />Unified Program Agency (CUPA) or authorized Participating Agency (PA). <br />481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check this box to certify that all work listed on equipment <br />manufacturers' installation checklists was completed. <br />482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check this box to certify that the installer <br />possesses all certifications and/or licenses the CSLB requires for installation/upgrading of UST systems. <br />483. APPLICABLE STANDARDS AND PROCEDURES - Check this box to certify that the UST system was installed according to <br />all applicable voluntary consensus standards and manufacturer's written installation instructions. <br />DESCRIPTION OF WORK - In the space provided, describe the work performed. Specify the type and the extent of work <br />completed on this tank system (e.g. installation of complete tank system, installation of dispenser secondary containment, <br />replacement of product piping, installation of turbine sumps, etc.). <br />SIGNATURE OF TANK OWNER/AGENT - The tank owner or an authorized agent of the owner shall sign in the space <br />provided. This signature certifies that the signer believes that all the information submitted is true and accurate. <br />484. DATE CERTIFIED - Enter the date the Certification was signed. <br />485. TANK OWNER/AGENT NAME - Enter the full printed name of the person signing the Certification. <br />486. TANK OWNER/AGENT TITLE - Enter the title of the person signing the Certification. <br />(Note: It is mandatory that items 478, 481, 482, and 483 be certified. In addition, you must certify that the inspections in either item <br />479 or item 480 have been performed.) <br />UPCF (1/99) Hwfwrc-c - 2/2 http://www.unidocs.org Rev. 02/16/00 <br />