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02`01-1995 TO 15104479178 p. @2 <br />1 <br />BrATE OP cAUFMA <br />3TATEIVA7ERREdr COMPI L80Ak0 <br />CERTIFICATION OF COMPLIAMCE <br />i <br />FOR UNDERGFK3l3ND STORAGE TANK INSTALLATION <br />FORM C <br />COMPCt TE A _QMRArjj NRM FQR EACH TMK SMEM <br />i <br />I. SITE LOCATION <br />STREET —. I LA - l +f f- ta v C' <br />clrY COUNTY . a <br />ys��w <br />i <br />t <br />11. INSTALLATION Imark al that apply): <br />ISZI 'The instal er rias been certified, by the tarn and piping manrtCD a�tur . <br />The i11Maticn has been kapected and certified by a registered professional engineer, <br />>9 The insts� tion has been nspectoc and approved by <br />� ttw irn f <br />p emarntenq at78Tcy. <br />Ail worts lutea an the manufacturees instatlativn checklist has beefs cornpietsd_ <br />�] The insta0atien rr<ractor has been certified or IirAnsed by 11199 Contractors State Lftnso <br />Board. <br />ED Anotner g8thod V►as used as allowed by the In"menting agency. (f',easo specify.) <br />I <br />III.OATH I cerlify That th 1 intomse` on provided Is true t0 the bast of my belief and know! *. <br />I � � <br />Tank Owriarl.0.ggnt <br />Date- <br />Prutii NarT►e ' <br />Phone { tom j 4'-(? - Q Pq <br />=AL AGENCY u% qN Y <br />STATE ioot�rry i JURISOCT" s FAOt{ m e <br />TANK r, U. it <br />�om1e O t�vo� Ti{I$ k6#4 NA1ST trt<AC *WAMP IT PEA18r APPL"Tt01f FORM A A 8 UHL <br />MAYf UEk PKU) PWEYiev9tY m inn/ <br />TOTAL P-62 <br />Z0 39V8 1S3M N3Q_109 8L16tbb ZZ:60 t,661/0Ef170 <br />