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ff <br /> UNIFIED PROGRAM CONSOLIDATED FORM A <br /> UNDERGROUND STORAGE TANK <br /> P R 0 9 H"0 9 <br /> 1�jl:� <br /> CERTIFICATION OF INSTALLATION tQ <br /> MODIFICAT ?$R0M `HbVN1 1- 1HP-AL-1F. <br /> I p=.116bpMZ222 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) T1 TTT <br /> BUSINESS NAME(Same as FACILTrY NAME or DBA-Doing Business As) 3. <br /> C Vto- �o�A <br /> BUSINESS SITE ADDRESS 103. CITY <br /> II. INSTALLATION MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that al2p] ) 483& WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT a l q? <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4830 <br /> 111. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION MODIFICATION 482a <br /> &"L�� Sira-4too S S�W-!5 U-f-1 <br /> CONTRACTOR LICENSE# 482b, I ICC CERTIFICATION# U 482c. <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 /> by a registered professionalengineer having education and ex erience with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 487. <br /> /W iLga�ti � 41L,/ kn�f <br /> CERTIFIER',S NAME(print) 485 CERT JER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 489 CERTIFIER'S ALATIONSHIP TO TANK OWNER 489. <br /> 0 1.TANK OWNER [1 2.TANK OPERATOR <br /> &3.CONTRACTOR n 4.PROPERTY OWNER <br /> El 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />