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May 30 08 08:45a RELIABLE PETROLEUM SERVIC 2098458953 p.2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/ MODIFICATION <br /> E: (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY 11)4(Ageacp Use Didy) t. <br /> BUSINESS NAME(Sane as Facility Name or DEA-Danrg crines Rs) 37 <br /> "� uc,` <br /> BUSINESS STTE A DRESS 103 BUSINESS SITE CITY ^ �� <br /> r / <br /> IL INSTALLATION I MODIFICATION PROJE&DESCRIPTION <br /> TYPE OF PROJECT(Check a([rhae afmfvl 40, WORK AUTHORIZED UNDER PERMIT °Be' <br /> j] I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> Q 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> III. CONTRACTOR INFORMATION <br /> NAMGTRACTOR OPHRFORJv1 STALLATION/MODIFICA ON *au <br /> 00-7>° � r o � z � i <br /> CONTRACTOR LICENSE H ° ICC CERTIFICATION# M, <br /> -7 s as 5 0 , <br /> IV. CERTIFICATION <br /> I certify that the itiforn ation provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has rnet She 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 standares and any manufacturer's written installation instructions. <br /> All work listed in the manufacturer's installation checklist has beer,compteted. <br /> • The installation has been inspecteddap oved by the local agency, or if required by the local agency, inspected and certified <br /> by aregistered fessional en eer ha education and experience with under olmd storage tank stem installations. <br /> SIGNATURE OF VAINKR WNER'S A _ DATE ff �- PHONE +n• <br /> Z�1 L J� 1 (5 10 ) :93 4 <br /> 3 <br /> CCRTIPIER'SN AL'{�inq 'ss CERTIFIER'STITI.C: asa. <br /> gfluL si rQ W <br /> NAMEOFCERTIFIER'S EMPLOYER(DBA) 43& CFIRTIFIER'S RELATIONSHIP TO TANK OWNER 419 <br /> ❑ 1.TANK OWNER 23�2.TANK OPER.ATO:t <br /> S �� �',/ ❑ 3.CONTRACTOIL C] 4.PROPERTY OWNER <br /> / © 5.OTHER AU'THORIZCD AGENT OF TANK OWN Elk <br /> UPCr t18T-C ne..(I212067)-v2 w.rwamidomorg Effecllve 01117108 <br />