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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION/MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) i. BUSINESS NAME(Sam as FACB.rrY NAME or DBA-Doing Business As) 3. BUSINESS SITE ADDRESS 77 toa. II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that aDoly) 483& WORK AUTHORIZED UNDER PERMIT 483h ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT S.OTHER DESCRIPTION OF WORK BEING CERTIFIED: 483c III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& CONTRACTOR LICENSE# 482b. I ICC CERTIFICATION# 482r- IV. 820IV.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 having education and ex erience with under ound storage tank system installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. 1 PHONE 487. CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST-C-1/2 Rev.(12/2007)