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0 0 <br /> From:2094640138 Page:3/4 Date: 1227/'20109:10:49 AM <br /> UNIk1611)PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICA.TION(Ord Cbm per mroa ) <br /> 1. FACILITY INFORMATION <br /> I. <br /> FACILI TD®(Agency Um Oa)y) — — <br /> BUSMR5.5 NAME(SaK�PACIIATTNA2xaaDDA-MInt B,aina A°) <br /> m. CR a. <br /> 9INF95 SITE ADDRESS <br /> ��lF�( • (TseXe1� vty h LL VYI <br /> I. INSTALLATION/HODIFICATION PROJECT pl SCIZMION wn <br /> TYPE OF PROJECT(Ch,ek all t),igty{IDlY) °p• WORK AUTBORI2ED UNDER PERMIT <br /> l] L TANK INSTALLATTONOR REPLACEMENT (Number or OGa): <br /> ❑ 3.PIPING INSTAI,.I,ATION OR REPLACEMENT CO't-IU d'c oo 6lo?)q wl+ "" l- <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4,UNDER DISPENSER CO TAWMENT INSTALLATION OR RF.PT.ACEMENT 16-5--to <br /> nrscRipTIoN or•wo x BEING TIFIED: c A l .� L-0 V-rD $ (. H'L<lq a uA 9 I STf'S 0A <br /> •aG.L_ ��S�s1ex�. _ <br /> fl9 tial l Lots secri-deV4DLuv(j LoUI bu s- <br /> z. 161" �l�lves t ied rob C i S1 h cam. <br /> $9191 STP-,-,' Los{aul L-11)1ve �A `b9 ,A `C <br /> �}gCP u sda U�Q <br /> %"j c ear, c'-k <br /> R I S`P its � (u'o vee}�e t,�dove iu Cd w-r Som w51,9 VC V tsl " skj'W <br /> III. CONTRACTOR INFORMATION <br /> n. <br /> NAME Or CONTRACTOR WHO PERFORMED IN T LATIONl MODIrlG TON <br /> Ihi l C'vr ah � ar, <br /> COMRAC7'OR L[CeNSB r ICC Cqb,E,^RTIFICATTON, <br /> �L1( V V <br /> IV.CERTIFICATION <br /> I certify that the information provided heroin ix tmer accurate,and that the following conditions have been Satisfied! <br /> 7'ha installer Bas mat the requirranaflts set£ori'in 33 CCR§3715,subdivisions(S)and @)• <br /> The underground storage talc. any PnmarY Pilling, and any 60cmdary containment was installed according to aPP]fcablo <br /> voluntary consensus standards and any mznufhaturar'&written installatlon hrstructlMs' <br /> • All work listed in the mmufactmur'S installmion cheeklirtho6 been etnnplotod. <br /> • The tnatalladon Bas been inspected and approved by ti, local ago or i£raf W by dye local agency,inspected end certified <br /> I b are 'st i en 'neer havin education and ox 'ante wit'under CUM Stora a tankoNE <br /> s teminst¢llations. °r <br /> I 40. <br /> SIONA F. .R OWNER'S DATE <br /> 9PA <br /> CCR7'FIE 'SNAME CEATIFIER'S TIT E: <br /> L�hrl eY—' u�t I c <br /> NAME Or GPATrr•IeR•S EMPLOYER(DBA) <br /> CERTMEWSRULATTO SMP TO TANK OWNER qtr' <br /> ❑ I.TANKOWNER l]3.TANK OPRRATOR <br /> ff9 DrrOeR ACUTROR)ZED TOR AGENT Or TANK OWNRR <br /> Rev.(J742847) <br /> UPCF UST•C•1/2 <br /> This fax was received by GFI FAXmaker fax server. For more information,visit:http:/Iwww.gfi.com <br />