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Feb 09 09 08:49a Reliable Petroleum 209-845-8953 p.2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF WST ATION f MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use on6y <br /> BUSINESS NAME(Same as FacilifyName or DBA—Doing BusinessAs) J. <br /> a rn a�460 r porn-, o <br /> BUSINESS SITE ADDRESS 105. CITY ia4, <br /> To e poftloo PoLr4we, �Y'i�A 0- <br /> II. INS'T'ALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(CkeckgglLauaaaly) iF- WORK AUTI-IORfZED UNDER PFRMIT 435b, <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 3-SI MP INS I'ALLAT[f}N OR REPLACEMENT �'?FE 10 0� � <br /> ❑ 4.[INDER DISPIrNSER CONTAINMENT ENT INSTALLATION OR REPLACE_VIEN1• vl <br /> 5.OTHER <br /> DESCR[PTION OF WORK BEING CERTIFIED: �B5_ <br /> ��ti.�a�•-,� a �1�c �-( ©,fir�c., -�-E'S•�- G4� �{ �C •�$ �1 Sv{Z� , <br /> �t n (Z /Ja-& O cci <br /> III. CONTRACTOR OR IN ® TIOiI j <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 492. <br /> P� �'v� _ Jl�r �/l C <br /> CONTRACTOR LICENSE# 4626• <br /> , ICC CERT[FICAT[ON# u 4MC <br /> IV. CERTIFICATION <br /> I certify that the information Provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions{g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> a registered professional engineer having education and ex erience with and ound storage tank system installations. <br /> SIG URE ONT` ER OR OWNER'S AGENT DATE 484. PHONE 437. <br /> cj- <br /> CERTIFIER'S NAME(print) 435. CERTIFIER'S TITLE: 486• <br /> r - y h (� P. ril }— <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) asp CERTIFIER'S RELATIONSHIP TO TANK OWNER 489- <br /> 1,TANK OWNER ❑ 2.TANK OPL'RATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> V ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> LIPCF UST-C Rev.(IV2007)-112 www.unidocs.org <br />