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FACILITY ID # (Agmy Use Only) <br />BUSINEFSS NAME ranw as FachlyName IBA <br />BUSINESS <br />ADDRESS 103, <br />cp <br />TYPE OF PROJECT (Ch ackgLdKo" 491L WORK AUTHOR12:151) UNDER PERMIT <br />❑1. TANK INSTALLATION OR RE LAI BIENT: (Number <br />0 2 <br />PIPING INSTALLATION OR REPLA TMENT, <br />3. SUMP INSTALLA770N OR REPLA( -%IENT <br />5f\#&j 7 6 6 <br />UNDER SaLCONTAINME1. '.lt4STALLAnONORREPL-ACM,.IEI%rr <br />5. OTHER 1611alho) i 'ki f 90W coid <br />ESCRIPTION OPWORK BEING CERT -9' S. <br />3, <br />4 <br />5 <br />10 R <br />NN <br />DISPENSER <br />ISPEN <br />I <br />spk I -n! <br />Rom.re a6(fxntr'v U P TCA(1� a!RC(_ <br />q <br />CSC orL x I 0--ol MLA leauus <br />b to (101 cz"6 ic f _Tk, <br />CONTRACTOR LICENSE # ICC'CMLTMCATION # <br />and it the following conditions have bernsatisfied: <br />that I certify that the id0rii1Ati6n.ptGv1 6111 Welk true' accurate, <br />j. The . installer has met the require; alts set forth in 23 CCR §2715; bdw Ions (9) and (h) - <br />primary piping, and <br />-was installed according to applicable <br />The underground storage tank; 3z,r any secondaryM*mneut <br />standards jj l-any-rj=nv&i0Uuers written i6stallationinsinictions- <br />voluntary consensus completed: All -work listed in the manufladtu T' -9 oncy, inspected and certified <br />"been. :d-ifid approved by fficlocal. agency, or -if required by ft loc agency, <br />The installation has . MSPOC nence with underground StOra 487. <br />d 44 <br />--A siona' - . Z= . PHONE <br />fes R! ed DATE -Lo 5 <br />SIGN q 6 126rt, (261 <br />48 . <br />ha <br />CER <br />A, d =ftink <br />-SN (pxim) <br />CMTIfMWSR$LA-noN HP TO TAMC OWNER <br />NpNIE OF CE�XTMWS MRLOytit (DE i- I TAW6 <br />W. 40 PROPERTY OWNER <br />Elz Elm OF TANK 0' <br />.5. OTj#A AU1140 <br />w.unIdoaA.r9 <br />UMF UST -C Rev. 1/2 <br />;3"d EV6919irsoal SJ040e4UO3 AI a'4T13 e6T :01 *'T IT clas <br />