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D PROGRAM CONSOLIDATED FORT <br /> UNDERGROUND STORAGE TANK (�, <br /> CERTIFICATION OF INSTALLATION /MODIFICA D CL-II���E <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> EN Rilb,11OF-i�1T LIE h,-r­ <br /> FACILITY ID#(Agency Use Only) L1111 T-_ 71 1 _ EPjS�' ��� E�' 1 <br /> BUSINESS NAME(Same as FacilityName or DBA—Doing Business As) 3. <br /> spw �'bFlr�.� COL-P ry SNEn-SP.1% 01-z .a�mp�') ICUC..sNG fzM a,Try <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> -7000 rrR60' -c-W CA-WN41 CA- RS2-3j <br /> H. INSTALLATION /MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR(DOS(, 1+52 -+¢tb Z4 2.QG74 <br /> ❑14JNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> X£P t.Ore.F_ V/R, f4AM L-A-R S£AU0 4- WW "PM R g Gut�AR-C�7 T K� <br /> Plea v/X +01 —SEA*' -701537 <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# 482c. <br /> rt74862. 52-,�.18r 76 - uT <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 a ence with underground storage tanksystem installations. <br /> SIGNATURE TANK YWNER ORO R'S AGENT DATE PHONE 487. <br /> a s/o4/o q peg ) 3t,;,-moo <br /> CERTIFIER'S N (print) CERTIFIER'S TITLE: <br /> .-ToS g pu spl Gt.E y G 94.)IA A-c. tM""E,e. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> `c ❑ 1.TANK OWNER ❑ 2_TANK OPERATOR <br /> (CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br />