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Fhb 08 13 08: 27a Elir IU Contactors 12094' '342 p. 2 <br /> UNUMD PROGRAM CONSOLIDATED 1?l RM <br /> UNDERGROUND STORAGE TANK: <br /> CERTIFICATION OF INSTALLATION/)V. 0DIFICATTON <br /> (One form.perproject) <br /> cif ' <br /> -�,3-arm r<�:: M... <br /> •,.�-e.,- �.-s-�-� -� <br /> FAC]LrI'Y ID#{Agency Use Onli1 I <br /> BUSINESS •'_ .. � �� � _ <br /> BUS S NA16M rmnexFaritityNxne or DBA—DoingBusimm,&) 3. <br /> a <br /> BUSINESS'SITE ADDRESS ,m. CITY — 104. <br /> ML <br /> a. <br /> TYPE OF PROJECT(Check all 4&1& WO`, ATMOli=UNDER PERMU 4R3b. <br /> ❑ 1.TANK INSTALLATION OR R£PLACEN EP4 (Nutib -or Datc): <br /> [] 2 PIPING INSTALLATION OR REPLACEMENT <br /> 0.3.SUMP INSTALLA170N OR REPIAACM LENT <br /> 0 4.UNDER DISPENSER CONTAR&IENT INSTALLATION OR RBPLACPKENT �• 1 J .1 ` <br /> S.OTHER <br /> DESCRIPTION OF WORK BRING CERTWM: — 493c . <br /> fay ktcte co tl�6 GC <br /> lec c� 3 5 h L; e 10 <br /> �G55�� teS�� i}5 � • <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION 1 MOD97CATIOV — v 4sa <br /> CONTRACTOR LICENSE#f \ 4L."b. ' ' 4 <br /> LIi6,00 6 AI C ICC CERTIFICATIONi� 516 � � b <br /> a+..Yx.'a' ?L•.'•-�wYi`.14Jn=XIPKFO4 .4.�.... <,._}� '�v� +�..- '.� ' <br /> I certify#hat the information provided herein is true,accurate;and that the following c nditions have been satisfied: <br /> The installer has met the requirements set forth in 23 CCR§2715.subdivisions(g)anc. <br /> • The underground Storage tank,:any prunary piping, and any secondary containra:t :was installed according to applicable <br /> voluntary consensus standards and anymaaufactL1r=s written installation insft cations <br /> • Ail work listed in the manufactu='s installation:cbeeldist has been completed. <br /> • The installation has'bcea inspected and approved'by the local agency,or if,required lylie localagency,inspected and certified <br /> by a re Bred pmfmsional en ' em having education andence wide undeigrout,a .1 oragetanksystem installations. <br /> SIGNZF T O R WNER'S AGENT DATE +K ' PHONE <br /> to i 61,o <br /> (P °sN 48& <br /> NAME OF CERTIFIER'S EMPLOYER(DBA).. CERMFIER'S REL A77ONSH .TO.TANK OWNER <br /> ; t t !, •. VGl �l:I uC lU l �J. j C! 1 1C J _l:rATIIC OWNER :: i�''21 ?1R OPERATOR <br /> 3.CONTRACTOR - �] 4.PROPERTY OWNER <br /> OTHER AUTHORIZE D ;3ENT OF TANK OWNER <br /> DRCRIIST-CRM(1217W7)=Irl wM��idocs oe� <br />