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1_11_1997 1 -52PM FROM FILLNER CONST INC 916 372 Wtt _ <br /> =TATE OF�DCAU11-6AMA <br /> STATE 1107ER P.cSQWCFS CONMf)J DOX40 <br /> CERTIFICA:T20N OF^f.'st:? iANCc <br /> {; :'Af F• ^f' r- ^-"+5 wa�n�TRR� l'iS is ' rt7 r <br /> tS ,C;RaR ,: OF, x :r.,:Kt o.r..,.,'REi .v �:jk�l <br /> gid: '.- <br /> Ci;`.c'.PLE7C:\7J�Y.�t4i+�L 4it'lrL:F�7n EkC,';1!?NK S'!>•;:.N' <br /> t.4 SITE LOCATION STREET city <br /> I i <br /> IL INSTALLATION.fmark ail That apply): <br /> The inststl!er has been certified by me tank and piping l�?1taG+UrerS. i <br /> The instti bon has peen inspected and reni ied iby a registered professional engineer. <br /> The instailatt04-1 has been inspected and approved by the impi©rnenlinc; ngency. <br /> All work}fsfed'on the manufacturer's installation checklist has beers ccntrnlc,od. i <br /> The installation Contractor has beer•,cert fled or licensed by the Contrartors State:icense&>atd. <br /> Another rciethod ivas used as allowed by the i.'npie(nea inn,agency. (Please&p=Ify.) <br /> ( . 1 <br /> l <br /> ( <br /> HL OATH f certify'chaf the inforinatton provided is tr'.E t0 the bes:cf lny 4etief and l.nalumledge. 1 <br /> Terik OwrerlApent -7-149B7-7 <br /> l i+ —_.... .._....._._ _.._.__.. <br /> ( . . ?rirg.Name i a.sl Phone <br /> ( LOCAL AGENCY USE ONLY <br /> STATE COUNna Jun MU',ra�,r Fn�:siirr# 7ANK4 <br /> TANK t.!).a <br /> rant 0(//Y:) TI'.S FQi(PA PdUST RE ACCOirF+A�tEO uY'r_RiJiT APP.1CF.i!ON FellrS Ad:S JNI,FSS T:iEY iiavE BEEM M7LE0 PkEYIeL'Slr cn?grox:7 <br />