Laserfiche WebLink
U <br />U1N1VM1Ll rIAV"KAM l.V1VJVU1VAIL+U NVK1V1 <br />UNDERGROUND STORAGE TANK FEB 2 0 2014 <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />If] ect.) <br />-ro <br />- <br />I. FACILITY INFORMATION Ft:fqMlT/ VICES <br />FACILITY ID # (Agency Use Only) <br />I. <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3 <br />CoUn�-r C,�k6 ^1(- <br />BUSINESS SITE ADDRESS <br />`7 <br />CITYCITY Ioa. <br />SYo <br />IL INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that apply) 483a. <br />WORK AUTHORIZED UNDER PERMIT 4836. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />[0'-5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c <br />7 <br />/ ! ie' FS—fee , <br />(ice � ��� �� � S ��t c��-�� V%,,,�;(er -iCvo-1 7�(13iv- 3e�/ <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />CONTRACTOR LICENSE # 4826. <br />1/ 9VLF <br />ICC CERTIFICATION # 482c. <br />1-4-T <br />IV. CERTIFICATION <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 ex erience with underground storage tank s stem installations. <br />SIGNAT RE OF TANK OWNS OR OWNER'S AGENT <br />DATE 484.PHONE <br />0 y // rl/ � <br />487. <br />��2-406e� <br />) <br />CERTIFI R'S AME (print) 485 <br />t)h leeii 5�I/t,/ <br />CERTIFIER'S TITLE: 486. <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />p /-e Gi /z -L- <br />E ! <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />7 <br />0'3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C - 1/2 Rev. (12/2007) <br />