Laserfiche WebLink
Jul 28 10 09:39a BAGLEY ENT IhIc "&Q31675790 p.2 <br /> UNLRED PROGRAM CONSOLI DA,rcD N,oRm <br /> UNDERGROUND STORAGETANK <br /> CERTIFICATION OF INSTALLATION MODEFICATION <br /> (OnOtOFM I-rPF0j0a) <br /> 'n N'proi, <br /> I. FACILUV INFORMATION <br /> FACILITY ED#(Ag&Kv 1-.k,On(v) I. <br /> BUS'INESS NAME(.'C.,--F:AC,7TJTVWA%4Fo,nRA-rkj,,I:Rto�� ,A,) 1. <br /> RUS[Na,'S SITE ADDRESS 103. Crry <br /> IT. INSTALLATION I MODIFICATION PROJECT DE.SC RJPTION <br /> 'rypFoE;I'ROJV CT(Check all that ap2l ) `'Ij® WORK AU'1*HO1UZLDUNDCftPFrmrr 4RIb. <br /> ❑ I.TANK lNs'rALLATION OR REPLACEMENT (Number or Date), <br /> 2.1'U'INQ INSTALLATION OR REPLACEMENT <br /> ❑ 1 SUMP INSTALLATION ORREPLAMMENT <br /> r'l A.UNDER IMS13E.N.SFIZ(:()Nl',%INMFNT INSTAI.1.ttTION OR RF.P1..A('LFMFNT ( 01 3cl <br /> �fi-OTHER <br /> L3F,%7CRII1*1'IQN OF WORK BUNG CUR7 IFIED: <br /> VApOX VIA p1jLj- Ai%JO <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CX)N1%U71'0R WHUFEk*ORMED INSTALLA'11ON IMOViVICAJ10N <br /> —I-,A huc <br /> CON-rRAC'i-OR LICENS17 g -"771CC.CERTIFICATION R 4fik <br /> 7 -7 11-? <br /> Q X13 t z ,rq <br /> ? () V/ <br /> FV.CERTIFICATION <br /> I certify that the information provided herein 6 true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requiremoents set forth in 23 CCR§2715,subdivisions(S)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 manufficlumr's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist lim.,been completed- <br /> • The installation has been inspected and approval by the local agency,or if required by the local agency, inspected and certifiod <br /> by a registcrcd profcssionat engineer having education and ex ience with underground store tank S stem imstallatiors, <br /> SIG; ll I.;01,''I'ANI<ovn41'rt()PO%Nr-,R'SACrNT DA:I'E <br /> 4117, <br /> I 1FJUR',S NAME(pr(print} 411 C1-XnFiF.R,q TM.F: <br /> j Z5's-rell 316A I)A,05k Lt;6 <br /> Z- !�5A 1214e=g A4,4 <br /> N -RFTATT()N.9MP TO TANK OWNFIZ 09 <br /> NAMHOF CFR'nF[F.R'.%RMPLOYE4 <br /> R(I)RA) I Cr-.k11n <br /> FI 'q <br /> ApAjsr--( �Ej TANK OWNER E] 2.-rANK QPFRATOR <br /> 4 ��* k.CONTRACTOR F1 4.PROPERTY OWNER <br /> Cl 5,OTT IFR AUTHORMED AGENT OF TANK OWNER <br /> ljper U.ST-C-1.12 (12/2007) <br />