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02/25/2009 :16 2094640138 ENVIRONMF"TAl_ HEALTH PAGE 02/0: <br /> UNIFTED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODLFICATION <br /> (one form per prosect.) <br /> L FACILITY MORMAT70N <br /> 'I FAC1L11y ID x(Atmry Ufn Cn yJ <br /> $USMPS3 NAMF(Pe, µV,Ie dDeq-�,edivr�q _ — <br /> 1: 9MFS5 174ADD <br /> r� Ia <br /> O <br /> n- INSTALL T70N i MODIFICATTON PROJECT DESCR611ON <br /> T0YPIF.tOAFNPXRINSTA dwek I pint R PNT WORK AVTHORf <br /> 7M UNDER PERMIT <br /> ❑ &PIPiNO INSTALLATION OR REPLACEMENT (Nnbw n,Diu): •u� <br /> ❑ ).SI.No N!iTALIwTION OR REPLACEMENT 1 <br /> 9�ER pISPENS;R COMAMMPM M'TAt)LATfON O LACEMENT K OCLV'? 2-0ryTI <br /> DPStgONIIO.•F WORD.BEMG CERT]P1P.17; " \\ <br /> !� W� C�Pr p(,frr C-�RSDILt,o� �i�k- I��.crY-obZ �w <br /> V`n lj:7:> <br /> I. <br /> III. CONTRACTOR INFORMAMN <br /> NAM2 OP CONTRACrOa wHD PERnORMEO M T N/MODfNICAT10N <br /> Q?M TZNSI �GnY`C Sr � G 4a <br /> I CONTRACrpR LICENSE. nq <br /> � fCC CERTPICATION a ,ne. <br /> oS s 2sy�cry_�T <br /> Iv.CERTTFICATION <br /> I certify that the lafortnattion provided herein Is true,accurate,and that the foRowln <br /> t <Installer has met the R twuditloae have been tatltlledt <br /> requirements sot forth in 23 CCR 92/15 subdivisions(g)and(h). <br /> • 'The underground storage tank, my'pritnary pfpfng, and any cependary dontaimrlerit was Installed aceotding to applicable <br /> } voluntary Consensus standards and any mane tenner'c written installation(netructlons. <br /> s, • All work listed in the manufacturer's installation chccklisc has been completed. <br /> The in lakion has been Inspected and approved by the local agency,or if r <br /> rat by the Ioca1 agrncY,lnapca and certified <br /> ,. Rs OWNER o NPJt"a AOtiNT education and e% encu+Lith andd d stun tank tem fnstallallatlq>a, <br /> oATR ua <br /> f C)7fTiPi2R'9 NA /� <br /> �� <br /> (P��t TTPMR'S TrFLE: <br /> NAM'OF CaR"1 ' R'g EMPLOY>:tt DBA) <br /> __ ti �,fr�-l�klt=•E C-' _ CEk�nTP�tE�R'S RET„ATIDNSFIIP Tp TANKOWNBR <br /> -�o''I-�7 0. � xOWN2R ❑ 2TANK OPRRATOR <br /> 'O t)r1 CA. 1d3 CONTRACTOR q a.PROPERTY owNER <br /> �� ❑ 1,oT MR ALt7HORt7PD AOEN'r OP TANK OWNER <br /> UPCT t15T-C•In <br /> Rev.moon <br />