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04/30/2009 19:49 2094654988 <br />r <br />HMC <br />PAGE 01/01 <br />UNI M.D PROGRAM CONSOLJODATED FORM <br />UNDERGROUND STORAGE TANK <br />CERT111CArITON OF INSTALLATION / MODWICATION <br />BUSTNES 1; SnE ADOUSS <br />2320 El borado Rd <br />H. INSTALLATION MODIFICATION PRO"M DESCIUMON <br />rx-Pa OP!.-RO.MCT (Check all dw <br />wopm)am�uNDERFERmrr 4ffik <br />0 1. TA14X INSTALLATION OR REPLACEMEW <br />(Number or is <br />L. 2. PTMG INSTALLATION OR REPLACEMENT <br />0 3. SW,4P IMTALLAITON OF, RFPfAa5KBNT <br />4-27-09 SR07=-,749, <br />[jef. WDER DtSPEWArk COI� LATION OR REPLACEMENT <br />��Aljoijh—� <br />DEscpjv-jjoN 6F woRK BwNr, cwnm: <br />Cold Start Monitor Certilication <br />09 I. -00a Tested all Sensors and Sensor Out <br />I Test all Electronic Line Leak Detector and Fall Safe. UAY 0 i 2009 <br />!All Tests Passed and confirmed operaMonal. <br />SAN <br />HEALTH L� <br />-MENT <br />M. CONTRACTOR IINFrN <br />rKsTALLAMN ROD• <br />Gavin WIlliams <br />1CCCEKTMCA170N# <br />8016288 -LIT <br />71certify:that the inf�rmation provided herein is true, accurate, and Qat the follovdag conditions haw beensatis0ed: <br />The 4installer has inct the requirements ad forth in 23 CCR §2715, subdivisions (g) and (h). <br />The, underground storage tank, any primary piping, and wW secondary containment was installed according to applicable <br />voluW,ary consessus standards and any manufwturer's written instaJIlation instructions, <br />Allrd. lifted i� the manufacturer's instaltation checklist has bow completed. <br />The "ation has been inspected and approved by the local agency, or if required by the local agmey, inspBeW and certified <br />by a reglAmvd 211ftsional �m' w having education and experience With wulormound storage tank system installations. <br />Af <br />RELATIONSMP TO TAM OWNER 40. <br />0 1. TAM OWNER z TANK omAwR <br />MCEKTurws <br />a(3. CONTRACM 0 4. PROPERTY OWNER <br />IL <br />E3 S. OTHER AUTHORM AGENT OF TANK OWNER <br />2210L�&Ala <br />