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-- --•-� cu79o4YJ1�J ENVIRONMENTAL HEALTH <br /> PAGE 02/03 <br /> UNIFIED PROGFtq•M CONSOLIDATED FORM <br /> CERTIFICATIONOF INSTALLATION/MODIFICATION <br /> ' cont ton++per�ierL) <br /> L FACILITY INFORMATION <br /> FACri.rI'Y ID p(.1te*ey Urr Only) <br /> f BtlSrN2S,9NAMr (¢'meKFAaIZYNAME aDHA-Ddn <br /> t BUSINESa$FTE ADDRP9S <br /> r 73 tot, <br /> �L ,omw, <br /> !<!. INSTALL,ATION/,MODIFZCATION PROJXCT DESCRIPTION <br /> T yr E OF PR015G7(Cficcic all fat eoelvl <br /> ❑ t.TANK NSTALLATION OR REPLACEI-MNT 4tJ' WORX AUTXORMM <br /> Ll2,PIPtNO INSTALL.ATToN OR REKLACEMcNT UMBER PERMt? t"n. <br /> d J,SUW INSTALLATION OR R? Number nr Dau); <br /> FLACEi4li:1V7' <br /> O ER CPENM Co M51A TION OR LA MENT <br /> NT <br /> toS��G Z <br /> OPSCRIPTTON OF wp <br /> $. $EtNG CERTIFI D: <br /> i <br /> i. <br /> Ki <br /> 4 93.0 <br /> AAJo <br /> i <br /> NAME OP CONTRACTOR wN0 P`RFO III. CbNTRACPOR INFORMATION <br /> RhfBn INSTALLATION/M00MCATION <br /> S`C'O T TI,34) �4.� <br /> Ct1NT' ACTOR LICENSE/ ~—G 0e/�/, I l't V 4 <br /> J?d'3j� rCC ER TION a <br /> y ['V.CER1I1177C.A'1'lO,Y <br /> 1 certify that the Information provfdcd herein is true,nccvrstte,and that the t'ollowi>wE eonOldaae have The Installer has t71et the requlremenls sM Earth in 23 CCR§271 S subA�' the(s a been eatlsDedt <br /> ° 'T'hc underground 9torage tank an (g)and(h), <br /> voluntary cnrMsus standards end anym� 00118, and any secondary costa ct wan in <br /> atallcd accordin to a <br /> ► All work Ifsted in the manufacturer's installation eh,ekli has barn rlftn 1 p p lsfion instructions. 6 l )ieable <br /> r The Install 'on has been inspected and approved by the local a enc <br /> b are St d ofessional en ' ear htsvin edu R Yt or if required by tho local a <br /> OF cation and ex erlerloC with under tmd Stora BrncR inspected and ccrtffied <br /> WNER'S AGENT DATE tan teff f2ttallst'iom, <br /> TIATER'9 NAlvtfi <br /> 1 C£rtTIFTER'$ <br /> NAME OF t_ZR tJ � E: <br /> ' FMPLOI'ER g�� 'Af, <br /> I psT'�9 TV�1/( i�—�� ` MMPIER'S PM ATIONSyl?Tb TANK OWNER <br /> IK oWNeR q L TANK OPERATOR <br /> 3' rrRACTOR ❑ 4.PROPERTY OWNER <br /> O S.OTFrr t AL714ORMD AGENT OP TANK OWNER <br /> UPCF 115 i'-C•1/2 <br /> �.ti uZoo'n <br /> a <br />