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REGEIVEC <br /> APR 16 2015 <br /> &= <br /> NVIRONMENTAL <br /> EDIItOG � COi®a,J _.__A F® <br /> gMMGRUM STORAGE TMK <br /> CEAZ']IQN.OF INST TION 1 ADD CATKIN <br /> (One form per project) <br /> R <br /> - <br /> FACUXrY ID# <br /> (AIIem}'Use Only) <br /> BUSINESSNAW(Sam+ as-Fao'y'-VMme orDRA Do&rg5sabimAs) j <br /> D51) C ��tlY�pia�liY <br /> BUSINESS SITE ADDRESS tm CITY <br /> vq:. TYPE OF PROJECT(CA wk all aw 413C <br /> . WORK.AUTHORIZED UNDER.PERM T N aesb <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Nor Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3_SUMP INSTAL TION <br /> PEN OR <br /> RF � I ��-}� f,!•, "�(G�� + <br /> ❑ 4.UNDER DISER CONTAOM <br /> y t�IPI ALLATION iOR REPLACEMENT <br /> 5.OTHER <br /> dN OF WO BEING CERTIFIED; ! <br /> t�1C.l v`R4rN `ih%..t C <br /> _{"R f.,,.' ,41/4t1Ll.{�.�✓ �e.%�1 p(5y_it.�����:t1� -'�L�.6 "lR�.. .sc-• ' .. .. . -_ <br /> ,Altt <br /> a r <br /> NAME ltOF CONTRACTOR WHO PERFORMED INSTALLATION t MODIFICATION <br /> E.L. <br /> CONTRACTOR LICENSE#/� <br /> �.., . �. Ca Cb#b A b C..ICt ru Z [CC CERTIFICATION## '} <br /> CER r <br /> I certify that the information provided herein is true,accurate,and that the flowing conditions have been satisfied: <br /> • The installer has met the requiaemeMs set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The undcqMxuld 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 msanufacturWs installation checklist has been completed. <br /> • e installation bas been inspected and approved by the local agency,or ifrequired by the local agency,inspected and certified <br /> fY a i e ' Professional engineer having education and a ence with underground storage teak system installations. <br /> 'SIG <br /> �QWNERNER'S AGENT DATE PHONE 487. <br /> CE TI IER'S NAME(print) CER•TIFIER.S TITLE: }}��''^^ 4K <br /> G <br /> ( eco X . <br /> T� , <br /> NAME OF CURTIFMWS EoM��MO�Y"EER(DBA)�j��' 4• CERTIFIER'S RELATIONSHIP TO TANKOWNFR '�. <br /> F-t.,.:t�E- cam l F`4-� mK3 ❑ L TAMC® ❑ 2.TAMC OPERATOR <br /> t3.CONTRACTOR ❑4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENTOF TANK OWNER <br /> UPCF UST-C Rev.(12IM07)-in www.usimlemorg <br /> �. fir. <br /> Z 'd 2ir69I9•bG02 OUI SJ0-43eJ4U00 nI e4T13 e91 :80 ST 91 add <br />