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Jul 27 10 09:05a EAGLET` ENT INC 2093675790 p2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND S'TORACG TANK <br /> CER . C,A,TION OF INS'T'ALLATION,f MODIFICATION <br /> (Onc roan per pr(�jcci.) <br /> L FACILITY INFORMATION <br /> FACILUY lU A(Agency Gss Oydy) <br /> Otis viLSsNAM h1 RaniaMPACI�L1'IYNAPAPMINIA fAwngManrwAn) ,�_ }, <br /> RtrCINF.Ss;;rrFAnnRKSS lad. cr�r-Y^ Ica. <br /> 7L®Dl.3Ai. WC-1 fro G <br /> II. INSTALLATION/MODIFICATION 1"ROJiIECT OESCR YTION <br /> I'}'PLUh YItCD,I(C'I'(C.hack nlr shirt gayly► 49lµ WOItK Ate-rIK)RiZF.D tJNr)CR PCRMII, 4H9h <br /> ❑ 1.'t'hNK INS'17t1•LA'I'ItjN Uft ICIsPt,ACCbiI;N'I' (Number or Dam1: <br /> ® 2.1'11'1746 1Nti'I'ALLATIUN UIC It Fa'I.r�C f;MI,NC t' <br /> LI ..uus.an as su r. •saoai oa�awuay..-au....,. aw A��i.L'V -'$Ve? <br /> UNDER DISPENSER CONTAINMENT INSTALLATION OR I'MILACt?MIrN7' <br /> 5 (1'HIRR <br /> OESCRIPTION CN;WOKK BUNG CLKTIF1L•'D: <br /> A-f •off 0 e ES='t- <br /> IIT. CONTRACTOR INFORMATION <br /> NAME OF CONIXACTOR Will?PILRFORMED INS'TALLAT'ION I MODWICATION 412. <br /> CONTRACTOR LICL'NSE V arzu I ICC CLRTII-ICATION# 4U`• <br /> 770- 90A ur_ of <br /> IV.CERTIFICA'T'ION <br /> I certify that the information providal bercin is true,Accurate,and that the following conditions have been satisfied: <br /> • The installer has ract the rcquircrnents set forth in—23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping;, and any secondary containment was installed according to applicable <br /> voluntary consensus standards And tiny manuf'acturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed, <br /> The installation has been inspected and approved by the 1=1 ngency, or if required by the local agency, inspected and certified <br /> by a re gistercd professional engineer having education and ex ience with undergraund storage tank system insWlatior'M <br /> SLG ltl Ul 'tANK UWNlik OR OWNER'S AGEVT DATE M1" I PHONL l4R7 <br /> •t'rIF78R'SNA (pruu) 4U CEti'1'I1�1L'!t'STITI,R; '�" <br /> ��$SL � Q.'oL1�•n,J �� � G�� � M G� <br /> NAMLUFCl>ICTu-IEWSCMrLOYER(DDA) <br /> fiG4xr< CERTIMER'SRELATIONSHFPTOTANKOWNr;R <br /> l?/ -:[ TANKOWNER ❑ 2.TANK OPURATOR�3. <br /> aKv <br /> CONTRA 1Ult ❑ A,PROPERTY OWNLR <br /> ❑ 5.OTHER AIri'1•IUKIr1{i3ACEWTOFTANK OWNER <br /> llpC'UST-C-I12 RarV.(I V211117) <br />