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1 <br /> br <br /> UNIBYED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK SAN J0AQU;t4 COU" <br /> CERTIFICATION OF INSTALLATION/MODIFICATI oNA;VNIAL <br /> HEALTH 4 . <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agmey Use Only) , <br /> BUSINESS NAME(Smw uFACnIIYNMff a➢BA-Wing autincs N) r <br /> •S0..kt'il9 <br /> BUSINFSSSITE ADD ss 1e3. CITY <br /> ta. <br /> G14aa- +)OLO I Shckkti <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 4ua WORK AUTHORIZED UNDER PERMIT Ons <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): 6 ISL/I/6 <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 5.OTtH'R DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> DESCRIPTION OF WORK BEING CERTIFIED: T 40n <br /> 1e,54cdA -Y(w _jiqu `PY-µt-(VCdI," -({f"KIF a)n $9, 41 do�scl �`U sU"kr <br /> M. CONTRACTOR INFORMATION <br /> NAME j (Rc <br /> .,OF�CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION <br /> bOry <br /> H r(,Lt(,Lt -e C—r <br /> CONTRACTOR LICENSE# 4M ICC CERTIFICATION# 4E.- <br /> 3 <br /> ns <br /> 31;141 - 633 — uZ <br /> IV.CERIWICATION <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 experience with underground stora a tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4u. PHONE W7— <br /> W1 0 <br /> 7Fs !S a-016 mP ) .Z(3 -(coP <br /> CFRTIPTER'I N�(print) 413 CERTTFIER's TITLE; 4w. <br /> µAl2i 1 �, tLTf4HAnI Co taueL OE Lf►� <br /> NAME OF CERTTFIER'S EMPLOYER(DBA) ege CERTIFTPR S RELATIONSHIP TO TANK OWNER 40. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> C ULS J u� • 3'coNTRAcroR [14.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCFUST-C-V2 Rev.(lirlaa7) <br />