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DEC-08-2010 21:47 F'.02iO4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE'SANK <br /> Errn Per ro s <br /> CERTIFICATION OF INSTALLATION / MODIFICATIO FORM <br /> 7FACICI-[� D#(Agency Use Only) *S <br /> BUSINESS NAME(Same�;FACILITY NAM _ <br /> r c-�& �� 3 <br /> BUS <br /> 5-7�ITE` , RES r 1csGti.v /�—� f�� <br /> W q� CITY j/)A c � � •����� �a <br /> rYPe 04 Project(Chuck su fha i <br /> © t•TANK INSTALLATION OR REPLACEMENT ,83' W0 K AUTHORIZED UNDER PERMIT <br /> Q 2,PIPING INSTALLATION OR REPLACEMENT (NV ABER or DATE). <br /> Ci 3,SUMP INSTALLATION OR REPLACEMENT <br /> © 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT '�- C'j p 7 <br /> A 5 OTHER <br /> ; <br /> 01=66RIPTI6hi L1F WORK 5WNG ChRTIFIE 1 <br /> 4130 <br /> i <br /> i <br /> rEQF CaNTRACTO WHO PERFp INSM <br /> �C N' 4 ! 1 ir.AT14N 4 " CONTKAUTOR LIC NSE <br /> ICC CERT.# �� <br /> I certify that the Information provided herein is true, accurate, and that the rting conditions have been <br /> satisfied; ollo <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 cecandary contairlmorg were installed according to applicable <br /> voluntary Consensus standards and;any manufacturer's written installation instructions. <br /> » <br /> All work fisted in the manufliteturer's installation checklist has been Cornpig(ed. <br /> ■ The inst2Uatian ha* boen insptctN and approved by the for agency,or,if required by the local en <br /> by a registered pr $Sionaf engineer who has education and experience wish underground Storag tank systemClnstallat ons•ifed <br /> SIGNAT RE OF TANK O ER ::. <br /> ROR OWN R'S AG.' <br /> DARIV TE 7HON t35b <br /> CERTIFI R'S NAME(pnn ��n�� <br /> X4 l-J 1€eti �� 11544 4J % t CCFO <br /> R r� �s TITLE; 4 6 <br /> NAME OF CpRTIFIER'S EMPLOYER(DSA) ae6b <br /> CERTtFIER'S RELATlpNSHlI'TO 7n K OWNER 0 C <br /> T.TANK OWNER [� 2.T NK OPERATOR <br /> 3.CONTRACTOR ❑ 4.P OPERTY OWNER <br /> l� 5,a rHER AUTHORIZED AGENT F TANK OWNER <br /> UPOF 1lwrtvrc»c-t/2 <br /> Raw,812006 <br /> Z'O/Z@ aoO:i vrZI BNO b SL94EE86OZ ,?t; .EZ 9Z9Z/8G/Z? <br />