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03/23/2009 05:03 6616349233 KERN CONSTRUCTION PAGE 02/07 <br />UNMED PROGRAM CONSOLIDATFD O: <br />STORAGE <br />CERTIFICATION OF I MODIFICATION <br />(One fbrm per pmjecQ <br />I. FACIIXrV INFORMATION <br /># (Agency <br />Inc � MT S) h M or/P s <br />f. <br />II. INSTALLATION / MODIFICATION P D ON <br />TYPE OF PROJECT (Chuck T�� UI fiORfp UNDER PERMIT <br />i2 L TANK INSTALLATIONOR REPLACEMENT orDwey <br />CI 2. PIPING INSTALLATION OR REnAcEMENT <br />Q 3. SUMP 1NJTALLATION OR REPLANTMENT� �r� �y❑�.4. UISFBI�iSER CONTAINMEN'C INSTALLATION OR Rh:PLACEMfiNT V `/1 <br />THM._.. 4. <br />'DGf4 tt&d VeehVko,)f <br />A IT <br />.1, <br /># / "" I [cc <br />IV. CERTNICATION <br />I eery that the InfotmaLton provided hereiu is true, accurate, and that the following conditions have been satisfied.. <br />• 'Thv 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 consalm standards and any manufacturer's written installation instructions, <br />• All work listed in the manufacturer's installation checklist has been eompicted. <br />• The installation has been, inspected and approved by tht local agency, or if acquired by the local agency, inspect <br />ked and certified <br />a .—A..►�...7 ....0 .......1 1..----- �---=--------.. .._ <br />cERTt 's NABS t <br />Nn <br />5 > IVV\ vv%-baz� <br />NAME OF CE�RTWMR'S EMPLOYER (DBA)litm A &4Y'4",SWL, Tj� <br />(6( ) C?y - j s vb <br />iv X-1 <br />CERTIFiM's RELATIONSw TO TANK OWNER — <br />Q t. TANK OWNER ❑ 2. TANK OPERATOR <br />A. CONTRACTOR ® 4. PROPERTY OWNER <br />© 5.OTHER AUTHORIZED AGENT OF TANK, OWNER <br />UPC1F UST.0 -1/2 <br />Rev. (IN2007) <br />