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_ .. .: 02/25/2669 "11:16 200130 EIdVIRONMENTAVTH PAGE 02/03 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TAMC <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />- cone mm ae. hm;M� <br />I. FACILITY INFORMATION <br />FACILTh' Ib x (dtrncy U,r OnlyJ <br />BUSINESS NAME(S-"NFA0W7YMA wDBA-aw.r ftiW .Aq �. <br />Sp—t&(g <br />SINESS FRE ADDRESS im. <br />Y <br />33 <br />�CtiJ �4 C920� <br />II" INSYALLAON/ MODIFICATION PROJECTDESCRLPTION <br />TYPE OF PROJECT(Zl=k alLthm emlvl nsa <br />❑ I. TANK INSTALLATION OR REPLACEMENT <br />WORK AUTHOR M. UNDERFBRMIr 'e3e <br />(Number nr vxte): <br />L PIPING INSTALLATION OR REPLACWENr <br />❑ 3, SUMP INSTALLATION OR RgMACEMENT <br />❑ , UNDER ISPENSER NTAWMENT INSTALLATION OR REPLACEM6NF <br />am tSLll <br />OPs �ronoN o � m0 C� TIFI ED; i�� •� <br />`�"' t-�I�TEcTd✓✓ � F3 SL�'�5 RJ,,r.� rV4 <br />&J <br />G'rdL <br />�Ecop- t>t > <br />LII, CONTRAC'T'OR INFORMATION <br />NAME OP CONTRACTOR WNO PERFORMEIJ DIP)CATION <br />wu <br />S <br />CONTRACTOR LICENSER ICC CERTIFICATION a ane <br />3G�tlt�s'— <br />XX- 414 0 7 <br />IV. CERTTMCATION <br />I certify that the Information prmided herein is true, accurate, and that the fallowing condltiaos have been Fatlsfled! <br />• The installer has met the mquiren"nul sct forth in 23 CCR $7715, subdivisions (g) and (h), <br />"The underIlround stornge tank, any PTIMry Ming, end any secondary contairmfeat was installed according to applicable <br />vOluntory consensus standards and sty, manufacturer ,$ <br />written installation instructions. <br />• All work listed in the manufacturer's Installation checklist has been completed. <br />The installWtin has been inspected d approved by the local ageney, or if required by the lova] agmey, inspected and certified <br />• b <br />ueation and ex arlence with under ound atom tank a tem instvlletions. <br />I A O NEWSAGENT- <br />DA ^•+ PRONE-- ,n. <br />? f D �?— t ) f—�6 <br />IN AMPfpdm) •� CERTiFBR'S TITLE; +m. <br />o(zEvw��) <br />NAME OF CE1ITIPMR'3 RMPLOYER(DRA) '"" <br />CERTIF@R'S RELATIONSFR,P TO TANK OWNER 1A0 <br />MRANKOWNER <br />❑ ZTANK OPERATOR CONTRACTOR ❑ 4,PROPERTY OWNER <br />C3 S. OTITER AUrNGRtZED AGENT OF TANK OWNER <br />UPCT ILPT-C -1l2 <br />Rev. (1712007) <br />