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02/25/2. 2U46�35 ENVI.ROMMaIT,iL WH PACE 02/03 <br /> 4 <br /> UNIFIED PROG.RM'I CONSOLIDATED VoRng <br /> i1N E RGROUNA S7'MA,GE'TA,NIK <br /> CERTIFICATION OF UN'ST A LL ATION I N 0,10.T,FICATIUN <br /> (One form per prnfact,) <br /> I. FACILITY INFORMATION <br /> r=,acrLrrY TD�(At.c„y Use v„tr) <br /> 147.15t1+fES5�iATviF:(71W n FACILITY NAWE cr DHA-Dok8 Hmfr—Aa) - <br /> 19l�SCN$SS SUP-.�AARUS oa. CITY' <br /> 194 <br /> n. INSTALLATION 1 MOD,IFTC,ATION PROM CT USCRIpTikON <br /> T"E OF PROM(.T(Choek emthet nno1 as.3, 41tK nU a"FPC1kr7Er)Lfir�Eti PERMtI a <br /> ❑ t.TA�x TNSTALI.ATTON(JR PXPLACRMFLNT <br /> a.PIPING INSTALLATION QR REPLACEMENT (ltiumhar�r TJ tte) <br /> 3.St3 0 INSTALA.A73q!,C)Ft RRF�AMMtN't' R CJU 5lda 1'� <br /> 4-tJ gDFR DISPENSER CONT.TA rN5TAL 1,ATTQN OR REPLA+=EI4fl6';�IT <br /> 9.07Ti1rA <br /> gPSCRIP Trp1 f Q------------- <br /> F,t~,OXK L+[ING CCFLTIFTED: <br /> aux <br /> 1ZE fun C-u.) ver� roc. - � Zoe ° cz t �- I <br /> M +CONTRAC O R INFORMA77ON? <br /> NA\ OF�ONTKACTpTt WF[4 F�kRFORMITJ f5rltr I hT10,1 r hEIJDiFTCATtCyN <br /> aA2a. <br /> G CJ Ca /9✓': ,t S Ica c..le-7-o-J Z V r Trig <br /> CONTRACTOR LICENSE 1'' 'qzb ICC CRR7TF1rA7f()N# <br /> 4R]c. <br /> 6-0 zm <br /> I'V.CERT'IFICATO <br /> I certify that the ID16rmation provided herein is true,serwatr,and that the fbllowing condidans have been satisfied- <br /> The Installer has mct the requirements set forth in 23 CCR 62715,subdivisions(g)grid(11}, <br /> f `The rzndergrptltld storac lank, any priTnarY piping, and srny secondary containmct wac lnstafled according to flpplicabfa <br /> v�lnr+t#1tY corlsctrsup a#andarrl anc3 any mAnuf4ct irer's wrltl;t'n inarallim n in,^,mccomg, <br /> • <br /> All,vmk listed in the manufacturer's itlsf llatiOrl checklist has been cotivltted. <br /> • The irstRIM.on has been irnspecttd and approved by the local agency,or if required by t1ic 10091 Menu,inspectcd and clrtifed <br /> b <br /> are"Oomd Ofcgsiolml crI 'treer havin eductation sm ex eiexce w7ih under and story tanks tem instAINtiorns. <br /> SIGNATURE O 4NK Ot�ATEA OR tayu'Iti>IC'S 4GSTvT <br /> �r DATF A. Pt <br /> cmTTrrP.P1<AMC(pript) 4xs <br /> Ct:1?T1i'TER'S'r'R't.E; <br /> +rte. <br /> Ic-a "�C 1'�rti5 1GrlMlM 1 <br /> NAMP bF CfiT'TTFTER ri PhTf'LT)l ER rT]T]A) "n fiRPT',PMR"S RSLATIONS-MP TO TANK OWNER <br /> 4Ru <br /> srcc1 e TU t 1 5CA U C;E-, I.rANk O WNP.R ❑ 2.TANK OPERATOR <br /> 1l�3'`t7WI RACTOR C34.PP,QPERTY OWNF,R <br /> ?H'R hUTF10AT I]AGENT Ot TANK 0 AnR <br /> L'PCF TIST.0.112 <br /> Rev.(I PJ10M <br />