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Mar, 25. 2011 1 : 15PM 10 e Pump Co. No. 1259 P. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID 0(Agency Use Only) <br /> BUSINESS NAME(Sane as Facility Name or DBA-Doing Banners As) 3 <br /> C t55tr rz S�R�tcc� s <br /> BUSINESS SITE ADDRESS ,m. CITY tw. <br /> L{07S k- , CY1F}IN 5i, �itac(<�cl , C� QS� IS" <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all thatannlvl 413• WORK AUTHORV.ED UNDER PERMIT 4mb. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2,PIPING INSTALLATION OR REPLACEMENT T'W,Y,(E3 SIZOO6ICI FJ� <br /> ❑ 3.SUMP INSTALLATION OR RULACEMENT <br /> ❑ 4,CINDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER (Wrae S11 Tj A4 SSWS.7Ci 0.1.-kwt L*;NV, —.TF— M <br /> DESCRIPTION OF WORK BEING CERTIFIED: SO';2 OtJ a83c <br /> gkCPLPtcE �XIsTIc1G It3Tcl2sTlT1 (�t S <br /> p`�7,btrrllJsm GAs ot.(tJ� Tp,+vK. 1.�rl�tlF.� N�>a VE�i7�1 . l'�doi <br /> PC1pp�.L �{C�71c-�"lrQs7'17'10.a. S�sKSo�. <br /> ,�SrAtt�c� tis Arne 99 LD -aeoa —IN& L%AK 7- C,7 Ct <br /> pts} �m l v rr+ ocrat t F, pet nn MZ`f Ll N 6 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482" <br /> E�brlLtd e 6x"(,�St-a9 <br /> CONTRACTOR LICENSE n "n ICC CERTIFICATION N �2L <br /> y3a 089 �3a0154 76 ur, v(rnT �aaa5- <br /> IV. CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied; <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 secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> by a registered Professional engineer having education and ex erience with underground storage tanks stem installations. <br /> NATUREOFTAN0 KORO SAGENT DATE 4W. I PHONE 467 <br /> 'IIFIER'SNA E(print � `` 4se' CERTIFIER'S TITLE: G��T <br /> 460. <br /> , t�c�'rnl�ro� <br /> P � 1 <br /> NAME OF CERTIFIER'S EMPLOYER(ABA) 4w' CERTIFIER'S RELATIONSHIP TO TANK OWNER aev. <br /> c `alp � , � ❑ I.TANK OWNER O 4.TANKPROP OPERTY ATOR <br /> OWNS <br /> G. `�c.,•V� QT�3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> [j 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF USF•C Rev.(122007)-1/2 wiv%unidomorg <br />