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M4546138 EIVVIRQNMENTAL HEALTH FACE 02103 <br /> UNrFM'D PROGRAM CONSOLWATED fibiZM <br /> UNDERGROUND STORAGP,TANK <br /> CERTIFICATION OF INSTALLATION I MODIFICATION <br /> cora fart,per Ptc+icCtl <br /> I. FACELrry IMFOk mATio N <br /> FFACTLrty ID q(Amry Usr Only; <br /> ' BU STNLS S NAME(V rc 0 rA0 JrV NA)4 a;DBA-Doll j bel-W AA) - <br /> > L <br /> !, HUSfIVESSREACDp�55 t� (91Y 9 <br /> o I . <br /> 11, INS ALL,ATION i MOD1F1 ATION PROJIECT DES ON <br /> 4f-Pn'TN0rN3TAr-LA-n6V6i <br /> TYPfi OF PROJECT(chock allchat$DalAtcKIt'fSThLLA1T13NORWORKAGTAOItrZBp LfNAQR PERMtTEPLACEMs <br /> SL"rWD 3,U"13 01SPELATfON OR R2Pf,ACE <br /> 4.CtN17$R AtSPfiNSER CONTAIT ME+rT FNSTALLAT►11N OR REPLACEME v'v t <br /> 5.vreir'.R <br /> DE-5CRrrrrotr OF wOrU�seer c Cr trrF�e� <br /> 41ac <br /> L_4 JOL IPi <br /> IIT. CONTRACTOR TNFORMATiQN <br /> NAMfp C3r�COtJ7'RACTC)R ti'i'1-fD PERPDRhrEf)rN5TAL4ATIaN!ttt]DIP]CATt6N <br /> Cs CC`s`t �r +y t rr bO •Rf +_�.�NIO.tl c ; �i-�i } <br /> CONTRA'TOR LICENSE rt !!tcc <br /> CfiR7 CA710N» <br /> ,3oa t oS X )CUIUltn j 14 <br /> r <br /> IV.CERTIFICATION <br /> I certffy that the Information provided herein is traej rccurote,and that the following conditions hive been ratlalildt <br /> • The instaHrr has met the tequirementg get Sorth in 78 CC,R§2715,subdivisions(pJ and 0), <br /> l • 'The underground storage tank, sin <br /> vplua+tary ny mRnuf Duping, and any ullandaty eonntrnrnert was ineta"ad acrc}rding to applicable <br /> consensus stands ds and an manufacturer F written instaf1sti+m instructions. <br /> i • All work listed in the manufacturer's invallaticrn chccldtst has been completed, <br /> • The Installation has been Inspectedd d veer by the local agency,or if required by the lora]agency,In <br /> b re 's ofessia al In ucation and ax enae with under ultd store tCd and ecitlfied <br /> ow*rsx r�ATR tanks tan fntstali■ziorl,, <br /> .". . <br /> F: MR, h <br /> CERTmZR•s TITLE: .,�. <br /> NAME OF CER R g F,MPLOYER(DgA) " r axrlFtmR°s �.ATIONSU1P TO TANK OWNER <br /> RtD I,TANxQW'NER +� <br /> U t4i to A.3 �� 0 2.TANK OPEUTOR <br /> A3 CoMA.CTOR <br /> d s.o'rFnSkt ®NOJFERTowKR <br /> UPcF isr.0•In AUTFOR[2PD.1Cry �N <br /> ANX <br /> n Z,=7) <br /> �r <br />