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Nov, 4. 2013 3:53PM No. 3522 P. 1/2 <br /> Fer 1�4 0 <br /> UNWIED PROGRAM CONSOLIDATED FORM MOMI BEnF ED <br /> UNDERGROUND STORAGE TANK NOV 04 2 3 <br /> CERTIFICATION OF INSTALLATION 1 MODIFICATION <br /> (One e form <br /> erproject) <br /> p <br /> 77 . ITAL <br /> :':at, FA ars:ic>LiaToi ;:. .. <br /> rACILITY ID#(Agency Use Only) <br /> USINESS NAME(Same as.'Bef1f0'Marne orDr 1A-/Dofrag 8vstrress&) 3. <br /> • j/rJ1�? LF '�� -�1 a n <br /> BUSINESS SITE ADDRESS , 1�• CITY' 104. <br /> IY::INSTI A. T Q .. . ..... .. <br /> l'�MUYI 'J� ATION ���'l::b +'SGRTFTION <br /> : <br /> TYPE OF PROTECT(Checknll t 4a3� WORK AUTHORTZED UNDER PERMIT <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Dom): <br /> [12.PIPING I'NSTALT.ATION OR REPLACEMENT <br /> [13.SUMP INSTALLATION OR REPLACEMENT <br /> 4-UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OVER, <br /> DESCRIPTION OF W0R-C BEINGTIFIED: dna <br /> 6✓j/ LycT 61't+id �LYtABtfxG / YY1GnAlf u y1k, l .ne 50".0 On 1), <br /> Ge�'/Gc[ I d?r wM�fl Vt rj —/V0 feG�+ �n td4"r..q Fi tY� ir,�nu i lc e�r.a IG+,r•{� <br /> J1 <br /> % ov4ttn�u,`� � �iO <br /> Caf,nc����f clnd -30 4S �Av1e 4gtc�vc:`; <br /> TIL., car�T c;T+a .,. ti TI41�T <br /> NAME OF C RACTO .AR WHO PERFORMED INSTA ON 1 MODIFICATION eat` <br /> r CM <br /> CO TOR LT SBA 4 ICC CERTIFICATION# dr1' ✓ 7ei1 4M <br /> 1 certify that the information provided herein is trite,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirents set forth in 23 CCR§2713,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 manufacturers writteninstallation 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 ex erience with underground storage tanks stem installations. <br /> SIGNATURE—OF 9ANPAOP OWNER'S AGENT DATE 494• 1 PHONE. 4a7. <br /> C TER'S NAME( nt) °a5 CERTIFIER'S TITLE. f y( 49a <br /> r'y <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER 40. <br /> ❑ 1.TANK OWNER ❑ 2.TANTO OPERATOR <br /> vi r'p vo r —) 3.CONTRACTOR ® "4.PROPERTY OWNER <br /> 4 J ❑ S.OTM AUTHORIZED AGENT Of TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 Wvw.unidoes.org <br />