Laserfiche WebLink
d <br />I, <br />E <br />9 <br />0 <br />�0946A6138 EW1RQNMFmTAL HEALTH PAGE 02/03 <br />UNIFIED PROGRAM CONSOLIDATED FORM - <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION I MODIFICATION <br />cone roan vK aro;�w <br />L FACILITY MFORMATION <br />h (Yoe r rACUrY xAMa Q DRA - D•i*r Anleeu MN <br />ADDRESS <br />II. INSTALLATION I MODtFICA,TION ,PROJECT DVSCR&"oN - <br />TYPE OF PRO)RCr (C =k all that arylyWORK AUTHORI; 8U UNDER PERMtr <br />❑ L TANK MSTALLATTON Olt RBPIACEMHNT (Number or Dau): <br />❑ 2 PIPING INSTAtd.ATION OR REPLACEMENT <br />O J, SUV INSTALLATION OR RFPLACEMENI' <br />LJ 3. aiiiER AtSPENSPR CONTAINMENT INSTALLATION OR`REPIaCEMENT SR,[ 6 Z12- <br />[LTJ S, OTHER -r-� I.. _..n <br />L2r-4De�F-: D"-Ot4� 1'om EA) 'r A sa <br />Var-o ma Fes- l�oaL- `- V R r7ci �P, U- zas' tA,�-3 b <br />ON De--Tz::Q6,2 ( `--B©q �I° rte <br />OF <br />cOMBACrOR LICENSE s <br />(Dc? %05-- <br />III. CONTRACTOR INFORMAT70N <br />ILLATION i MODrmcATtnt,' <br />iCC <br />IV. CLRTI11CA'TTON <br />I cR!rtify that the Worrua6on provtdrd herein Is true, accurate, and t At the Fetlowtng mididont have been tattsltedl <br />• tl�e installer has rnet the re <br />quirernents set forth in 23 CCR §2715, Dubdivisians (g) and (h), <br />• •Thc underground storage tank, any prlmnty piping, and any Secondary contairrtrunt was irfticd according to 9POmble <br />voluntary consensus standards and any menufkchrrer's wHtten installation instructions. <br />• All work listed in the manuthcturer's lnsiallation checklist has been completed. <br />• The installrttion has been inspected and approved by the local agcttcy, or if MgWred by the local agency, inspected altd certified <br />b are stared ofcssional h education and ex coca with under ound storage tank svatenn inaGll.+ie.,. <br />_ rANxowxsrt n,oe•�.� _ <br />CERT MMR'S N <br />MTMM's TrILE: <br />PLiMME OF CPR7T�FiFR',9 FMPLOYk� (il0A) Cll"77JER'S RELATIONSFIIP TO TANK OWNER <br />�I'• �� Tj�T%%GKT CQ 0_ 1 OWNER ❑ Z TANK OPRRATOR <br />3. CONTRACTOR 0 4. PROPERTY OWNER <br />❑ S. 0 SER AUTHORI= AOIiNT OF TANK 0"R <br />UPCF Mr.0 • 1/2 <br />Rsv, 0 =07) <br />