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i3NIMD'PROGRAM .CONSOLmATFD FORM ` ?` 3 <br />?i a! <br />UNDERGROUND STORAGE TAINK <br />CERTIFICATION OF ]INTSTALLATION/MODIFICAT19ftl 22 1 <br />o. <br />(Qne form;Per Protect)... <br />�-� . : 'kte�"°"" s4:te�,.�, �r i ev_s-x �e.�r&sa�tt. w �E aw�i.,�xr:�psw�—•�'4s'4ces x>'°ac'+^s'.e � e :.?� � na` �e�i��� �GS�`�',' ' <br />i <br />xsg.r;-.x;. <br />FACEMY )D # (Agency Use Only) <br />BUSIISES ..(Same,esFacwrj,W4meorrgDR4j(-�Dtoing,Bnsiums sJ . f 3 <br />TYYI\ <br />BUSIINTESS-SITE ADDRESS ttu. Y �� <br />C1T <br />M Mr } a Rw.i •Ls`k",•wci •5v.� F�P'.fA^' eaa: k.�-!i�"^ A4 n'Y:tl1.4 +�faF.x+aSi%.M.w !d'� a•I•.�Y�'ETbk"4.d �a � •-t i'kn'"R M,. � _, � .. 'Pv.a'U�' <br />nay n vQ. <br />WORI:.AUTTiORiZED UNDERPERivIIT 483i+- . <br />TYPE OF PROJECT (Checkall&g nnh,) • . <br />Q . 4. TANK'DVSTALLi�TION OR REPLACEMENT : (Number or Date): <br />Q ?.PIPINGlNSTALLATIONORREPLACEMEINT <br />0 3. SUMP INSTALLATION OR REPLACENWN'T �`..� .'� \✓ cc//�� " <br />AIIQh�NT INSTALLATION OR REPLACEIVMNT . <br />_ 1 <br />Q, 4. UNDER DISPENSER;CONT ' <br />3: OTHER <br />_._...._ DESCRIPTION.OF_WORI:BEING-CERTZIED.----- -'- <br />i�r^!`�y1� <br />47) <br />LLY <br />r s'<' N,bt °r'Y '• ry .^_'+�7•—� g#'P.i_ t y��"e'' .. r° <br />' - art b14 .A.er1 "a tfy k K - ari:3• eJ."Y <br />^ •µ�� ..sig$ :.!.h.MaF 4 .R ate, T : `6✓�q -.Yv <br />vid <br />,. asr f• <br />N OF CONTRACTOR WHOPMO 1Q�STALLATION.J MODIFICATION <br />{ <br />asze. <br />ION'th 1 <br />CONTRACtTOOR LI£ # ICC <br />> <br />"""_ ` accurate, anal tleaY Elie foiiowinb conditions have b satisfied. <br />I certify that the information provided herein is: tine, subdivisions (g) and (h) <br />encs set forth in 2� CCR §2715, . to ¢hcable <br />l7ie�ter has met the requirem secondary containment was installed according aP_ <br />and storage tank, '�Y Im ' :P�'ng' and : ?nY af�on instxuctious. <br />® ;Che undergro, . maniufacturer s written install <br />��oiuniarY csensus standards and ally feted inspected and certified <br />d the a er>s'.kaaliatjou checklist Sias -been comP . wed � the local agency, <br />All work iiste zoned by tNie local agency, of °if req Y Q Stem'instzllations. <br />'life instaiiation .has been .inspected and app {a�. <br />® aaa- PHONE <br />d •ofessional eer.havin education and ��� �.unde and Stora e 1 t ,, <br />a' stere S AGENT ". , J �A A <br />NATURb OF TANI ,PW ,ER OR OWN£R' <br />{86. <br />419. <br />�RTIEII;R'S2�AN (PnT't.-�j- <br />FIII'TOTANK <br />ON\lNER <br />{ss. sRELAmOASTE'..[ <br />R• <br />SFMPLOY£R(DSA) -OWNER <br />OWNER <br />ROPERTY <br />3. CONTRACT O ORIZT;p A�� OF TANK OWNER <br />CA_ <br />TI3EIt :4UTH <br />aeNvsr unedos?_g . ' <br />LrCF X3sx-C Rcv. t1�=0a.i7 = xn <br />1•d ZbE9T9b60ZT sjogoe4uOO AI OIT13 dbS=ZT OI ZZ inC <br />