Laserfiche WebLink
" E I ® E®i.te6 Contractors Inc 2094010 <br /> l` 2 P. 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> AN JOAQUIN COUNTY UNDERGROUND STORAGE TANK <br /> ENVIRONMENTAL CERTIFICATION OF INSTALLATION/MODIFICATION <br /> HEALTH DEPARTMENT <br /> (One form per project), <br /> I FACILITY LNFORIIIATI02V <br /> FACILFrY ID k(Agency Use O.,hJ - T1 �.; <br /> 1 L=TH <br /> BUSINESS NAME Fa iliry Nawor DBA Doing/Iasiww,!s) y_ <br /> BUSINESS ITE iCITY <br /> Iw. <br /> INSTALLI# 1O�I}114UD1FIIOrF PROJECT-'DESCRIPTION <br /> TYPE OF PROIECCI Checkallthat anoly) °63' WORK AUTHORIZED UNDER PERMIT <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLA77ON OR REPLACEMENT <br /> ❑ 3.SUMP DST <br /> ISPENSER C OR REPLACEMENT •�C-k'/^—'v <br /> a.UNDER DISPENSER CONTAWMEMP INSTALLATION OR REPLACEMENT <br /> 5.OTFiEIt <br /> ESCRB'TION OF W ORK BEING CERTIFIED: °$k <br /> a�U2r✓fi�G� 1�z� <br /> III.', CONTRA(TOR INFORMATION <br /> NAME F C i T C70R lt+HO O� INSTALLATIION I MODIFICATION 4g <br /> CON RACfOR LICENSE# aB36' FCC CERTIFICATION# 4at4. <br /> CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)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 manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> b are 'stered rofessional engineer havin education and a erience with underground some tank tem installations. <br /> SIGy' URE OFT OWNER OR OWNER'S ACENT <br /> DA // 4". PHONE 497. <br /> U <br /> ERT7FIER'S;{. - (print) °es. CERT E: +re. <br /> NAME OF CERTIFIERS EMPL�YER(DBA) °�' CERTIF •S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ I.TANK OWNER 02.TANK PROPERTERATOR <br /> Y <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5 OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(122007)-1/2 www.aoidoes.org <br />