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EMFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />. +r +MCr <br />Ps FACtt.ttr NAME or DBA - DO* Diadma As) <br />021 <br />(OW form perP-jest.) <br />TYPE OF PROJECT (Check _` ° L WORK AUTHORIZED UNDER PERMt r <br />❑ L TANK INSTALLATION OR REPLACEMENT (Number or Date). <br />❑ 2. P&WO INSTALLATION OR REPLACEMENT <br />❑3. SUMP INSTALLATION OR REPLACEMENT <br />P UNDER qFV;eR . A1NME TIN TAUATION OR JJEPLACEMENT / <br />I ' I I I . r U <br />t[.L <br />50;,-AdT ,J <br />CONTRACTOR LICENSE P 4M ICC CERTIFICATION # <br />lieo ®®tel] I-re%.Oft t t e zL® ."% <br />IV. CERTIFICATION <br />19 <br />I eertlfY that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />The 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 consensus standards and any manufacturer's written installation instructions. <br />All work listed in the manufacturer's installation checklist has been completed. <br />• <br />The i ti has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />a re ' fessional en in education and experience with under ound storage tank system installations. <br />s r $I DATE ire.. FAnNiz air <br />'S NAMe (print) <br />NAME OF CERTIP)Ett'S EMPLOYER (DEA) <br />zMjOXt , <br />TITLE: <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />O_WA<K OWNER ® 2. TANK OPERATOR <br />3, CONTRACTOR 4 a, PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF USS --C- 1/2 <br />Rev. (IZ12007) <br />