Laserfiche WebLink
WbUD PROGRAM CONSOLIDATED FO ,. <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) �. <br /> 2196 — — <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> e`!��CAC <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 32/ 2c S/�Z� <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that Qply) 483x' WORK AUTHORIZED UNDER PERMIT 493b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT /a <br /> F-14.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 5 Q ®�l/�� 3 87- <br /> Lj-5OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: �- 493c. <br /> ( , 1�•'(�i4��% ?''51 irdl/ fi.a1 Srird✓t SC- 5.1 A, c� i �� T 3 1-��� �u`"I p <br /> 3. ft`=�//Q{..� Y /ec�(_,.9-y G1lt ?✓j /Kc�,�J�G /.�/J/c��c � O/J J/GL'(�c.Z- ��1 ��n'r�� . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 492a <br /> CONTRACTOR LICENSE# 4826" ICC CERTIFICATION# 4820. <br /> ICA ZZO V3 S 3oo833 ./T <br /> IV. 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 /> by a registered professional engineer having education and ex erience with underground storage tank system installations. <br /> SIGNATUREi� OWNER OR OWNER'S AGENT DATE- 494. PHONE 487. <br /> CERTIFIER'S NAME(print) 485. CERTIFIER'S TIME: 496. <br /> C�r/L <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488" CERTIFIER'S RELATIONSHIP TO TANK OWNER 489" <br /> � 7ax �jc,g7J y�C_. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 67y/ 5-,GL4,+ C!, WL3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> S.OTHER AUTHORIZED AGENT OF TANK OWNER <br />