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Apr 07 10 07: 57a2 IV Contactors 12094G1G342 �" P.1 <br />j <br />i3NIFIEEI PROGRAM CONSOLIDATED FARM 'tVp 201p <br />UNAERGROUM STORAGEIsNI{ $� <br />CER 'CAT.�ON OF iI\TST :ATION fMQ]DIFI Iry <br />FACA;PTY ID # (dgemj, Ike Only] <br />BUsDgssN e at Facility 2Vame or 2)B,4 - D ingBusinw.&) <br />�. <br />3. <br />BUSINESSBITE AL)D I4i. CLTY <br />RE W <br />TYPE OF PROJECT. (0=kaff thatarmtvl , . WORKA:_ <br />0. L TANK•PNST'.ALLA TION ORS <br />E� '2.PIPING WSTALLA (Numbcr o Da*j ITED <br />LINKER PERMIT 4s3tr. . <br />.®..3.'SLW INSTALLAyYON OR REPLA'CafENi <br />r <br />.:D.Q':34:: U.NDEttDEPENSBR'CONTAII�NT.INSTAi.T.ATFON.ORREPLACEM& <br />- OTHER .. <br />_�____.��-;UESCI2T�'TION_QF_W-ORIL.BELNG.C�RT <br />am ,� <br />IQAMEOFCONIRACTOIt' W40PERFO INSTALLA ON/MODIFI TION^ <br />_ <br />-, 4$$i, <br />CONTRACTOR LICENSE# 4=LICC'CERTIFICATION# 482c <br />I eertify shat the an%rmation provides! herein is true, ae cuirate, and that fie %llowiny; coflditions.have^been satisfied: <br />' <br />.. . . <br />.. ®;.. The.zusrtaner:has-met-the ;.... ' . . -.._ <br />zegtu e�nts set forth,in Z CCR 12715; -sOdivisions az d <br />The u**nder% . . (b) . (k) <br />vo "e tank, 'anY per' pipmga and any. secondary, cantainment:was installed according to applicable <br />h2tmyconsen=-standards•and'anjr,IItaYRlfarft r5Gtiltt�> j] Qn'1BP%iICICtiQTJS: <br />• : ..AII work �isted in -the ms iufactiaearr —mStanabion che' dibya st iias beeiP conipt�ted • : <br />• •The itismtia.6On has.be beim iiected and. approved: by'tbe Icrcal agency or'if the Ioca1 agency, inspected and ceitified <br />... .. a �. <br />fusional eer.havia educatim and e:. ence with andound. a ianic stem iastaiEatioPis <br />crr err naratdK OW�tFR'OR OWNERS AGENT' .. <br />l ,+-OATE <br />4K jPHONE <br />o F. <br />CEtTWM'S- <br />N7AIv1I (pa+1t)CER.41 <br />..�--�-+-�:. 486. <br />NAME OFCERTIFIER'S McLOYER (DRAY, <br />CPRZgiER*s:REL ATIO <br />- _ To aANK owNEFi <br />NSFIIIa 469. <br />-. - -j]'`2: TANMPERA.TOR <br />LL <br />GG . [(' a. CONT 2ACT OR .4. PROPERTYOVI'NER <br />:'S. OTFTEPtAUTHORI7I7? AGFNT OF <br />TANK OWNER <br />'° UPCF <br />