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U11tI)rIEB'PROGRAM .COI�*SOI,IDATED FORM <br />UNDERGROUND STORAGE TANS <br />CERTI F WATION OF INSTALLATION/ MODUTCATIQN <br />• .(tate form.P�Prnl�).:.__,' ... , . ' <br />J L <br />FACILITY ID # (Agency Use Only) <br />Van <br />ill I I <br />BUSINESS NAME (Same as Facility No •e gr DBA - Doi -g B -b --As) 3. <br />BUSINESSS1TE ADDRESS _ CITY ,aa <br />tzm <br />_�. <br />- _ <br />TYPE OF PROJECT (Checictt tliar 'sem WORK. AUTHORIZEn UNDER PERMII +sse. . <br />(] 1. TANK INSTALLATION OR REFI. i( ---MFT': (N=bvorDatc)•. .�.(�j% �C� f_ . <br />0 '3. PIPING INSTALLATION OR RS? A Nrl <br />5 l iVIJ� V !-3 ,2, <br />l] 3. SUIisP INSTALLATION OR REP.! .0 tom!' <br />❑ 4. UNDER DISPENSER CONTAIm/. Nr INSTALLATION OR REPLACIDdiNT <br />S: OTHER • :. . - <br />• <br />- ----- DESCRp-.noN OF-_WORKBE1NG.CER.]_-- -- <br />C>;.xre,51� r ...... <br />tj7l LST..pwWr c -c em—T • ccr L15 <br />Pout i~em(* .moi tree Cn��.2t �u' lcI KSS �CrSt c. lU c�citlan . <br />bplw btl(I..!(zz �' ,e:� �ecec�dissy inIji li on +4.0) iE;Z <br />- f <br />EM <br />E.l OCT, Tai1T�'. Q' <br />CONTRACTOR LICENSE # ICC'CERTIFICATION# <br />I certify that the. information provi ed herein is true, accurate, and that the following conditions have been satisfied: 1 <br />_ <br />The installer has menthe requires eats set forth, in Z CCR'§V15,-siibdhisious (g) and (h). <br />• The underground storage tamk. my primary Piping, and :any secondary conW ttrmnt was installed according to applicable <br />voluntmy consensus -standards -a: _ rny, actxuEr's written installation -instructions. <br />o <br />AN wort: listed in the manufacivl e i installation cheoidisf has -been connpleted. <br />. The installation has been inspect i and approved'bythe Iocal agency, ormif required by the local agency, inspected and cerUed <br />F'NANWM <br />ire ' tered rofessiona) en er Lm education and experience with mader und.st tank installations. <br />RE OF TANK OWNER OR OWNI's 's AGENT DATE PiIONE 497. <br />• '�- �s � . . • Cs�. - x•1-1:2 : ('��1> -� i =3� <br />-(XR MR'SMU1 °&� TMER'S EMPLOYER (DBA) �. sas . CERTiFIER'S RELATIONSRIPTO TANKOWNER +$9. <br />! ',1. ANK OWNER' ©' `2 TAt&-OPERATOR <br />`1��� ��� 11��{•+c,7 f Qv' '�.3.CONTRACTOR.. ❑ 4. PROPERTY OWNER <br />_ ❑ S. OTHERAUTHORIZBD AGENT OF TANK OWNER' <br />as UPt F [IST -C Rev. (12!2007) - Il2 www•.nnidocs org' <br />S'd SJO-40egU00 AI agTIA et, i=LO i3T LO 2nd <br />