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Et`lVZRI_INMCFITAL HF'1_TH <br /> PAGE 01102 <br /> UNI TED!PROCI RAM C01-M EDAM FORM <br /> I'V(/ 2 0 2008 UYMIIGROUN11)STtORAGg TAM< <br /> CFItTIFICATION Off'INsTA,LLATION 1 MODIFICATION <br /> ENVIR TH (One form per project) <br /> PER 91T/SFRVICES T. FACILITY INFORMATION <br /> F CR.i TD (eRerrrt <br /> I <br /> US] ESS NA F, amt.ns f'abifl y Ncthre ar BA-f�ra'tfp Rna1n�.Stifs) <br /> e. tFt� ESQ <br /> BU9TNE55 9tTE ADLIRFSS MT i CITY <br /> II. 'NNTALIL,A--ONIMODMi CATTON PROXIECT DESCRIPTION <br /> Tit or Prta.rw CT r�h�C�4�ldt� 1 Haas WORK AU-MORTZED UNi7FR Prrl,it'irr 717. <br /> Q t.TMK INMLLAMN 0R AEPLACCLII;NT <br /> p z.PTI'ING i `.MLLATr()N OR RFPLACFMtNT (Numkm or Dat-); <br /> C7 3.SUM?tNSTALLATIO 0?REPLACENTEM <br /> © OWDE I9PENttRCONTAIN, ENTTh5TAILA7' RPACMNT ST f I-4D, G <br /> DES RIPTION OF BETO?CTIFIED; 3� <br /> nrt3c. <br /> I <br /> W. CO),'siTRACTOR WOWM,A.TION <br /> NAME OF CUIVIRACTM WHO PERI.7RMED INSTALLATiON 1 MODTFTC.A,TiOn ss n <br /> �q i <br /> CONTWICTOP.LICENSE N ICC.C•rATTFFCATiON <br /> -3, 4 ,Q o <br /> TV, CERTIFICATION <br /> I certify itkAt the information pre�5ded herein is tune,accurate.and t11at tate fblinaing cnoditions have been satisfied: <br /> • The iri tatllct hes met the rcquiretnents set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • Zhe undergmtthd storage tank, any primary piping, and any sot-ondary containment was installed according to appliCable <br /> voluntary conse11.5us standArds and any manufacturer's written installaNcn instntctions. <br /> • All work listed in the tnattufachtrer's installation checklist has bcen tOmplctcd, <br /> • The installation tins been inspected and approved by the local agency,or if rcquited by the local agency,inspected and ccrtitred <br /> b art ;stt-ctrl Utafess{anal att�gincer llavitt�education and ex Crience With tinder and storage tanks stern ihstall&tions. <br /> SIONATURI:(31` (,pIVTJ nR owNT'2'S e1CFN7 DATE <br /> p M1FA. /PHO II 717 <br /> CERT,IF , ns)� l- 't` CERTII�II R'S TiTT.F.; «. <br /> �s <br /> NAtiTTa�r�t ItTiFTGR'g 8R(bBA1 OF, CFRT?Plt R•s RPLATtONSHM TO TANK OWNER � <br /> P�l� I.TANY,DAWYPR ❑ ,,.TANKOPMA11:11 <br /> int• v 1►.1t�N ^� 0 3,C0N7RACT01Z ❑ n_rizempTy OWNER <br /> 1 E3-5.07VIN AUTHDRIZED AGENT OF TANK OWNER <br /> UPCF 1J1,4T-C RAv.(11121Ia7).1JZ wwq+,unidbc-cor t <br />