COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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s UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION / MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3. BUSINESS SITE ADDRESS 103• FITY _ _ 104. 16 Ll� II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT (Check all that aDDly) 483& WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT ❑ 3. SUMP INSTALLATION OR REPLACEMENT 4� 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 5. OTHER DESCRIPTION OF WORK BEING CERTIFIED: 483° III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482& CONTRACTOR LICENSE # 482b. CERTIFICATION # 482a JICC �y 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 having education and ex erience with under ound storage tank system installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. /PHONE 487. 1 l CERTIFIER'S NAME (print) ) J 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 t 3. CONTRACTOR ❑ 4. PROPERTY OWNER ❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST -C - 112 Rev. (12/2007)