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INV <br /> M �1 <br /> UNIFIED PROGRAM:CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK U t VEL <br /> CERTIli ICA'TION OF INSTALLATION I MODIFICATION' <br /> (One form,per project). _ MAY-1 o.201-1 <br /> tr. <br /> FACMr Y ID#(Agency Use Only) I E V1R N E AL <br /> _ 5 EA T <br /> BUSK =Faedlity i, -o-DBA-Doing BusinessALs) 3. <br /> BUSINESSSITEAUVReS5 CITY 104. <br /> �.. <br /> TYPE OF PROJECT(Check all rho nnvh; 483& WORK AUTHORIZED UNDER PERIvfIT 493b. <br /> Q.i.TANK INSTALLATION OR REP]. CANT. (Number or Date): <br /> Q 2.PIPING INSTALLATION OR REP) k(MvIENT <br /> 3.SUW INSTALLATION OR REPI.'CI WENT. <br /> 4:IJNDER DISPENSEtt COA'TAINHC V'INSTALLATTON OR REPLACEMENT <br /> Q.5.OTFIF•R' _ ��. 7 <br /> DESCRIPTION OFWORK BEING CERT. TED: 4M. <br /> • ��.��_1`r �•` r ! Ian � 9 <br /> t7 elf ``. i'::f Ch i h ? c � °c, �? <br /> �C 9Q . <br /> bt <br /> •zy�a a, ��-e+e�rne <br /> � -sr -k j..-? 'kft-OR7�a <br /> NAME OF CONTRACTOR WHO PERFOP.I IED INSTALLATION,MODIFICATION eta <br /> CONTRACTOR LICENSE# 4=x ICC CERTIFICATION'# ` <br /> I certify that the information pro-0 :e I herein is true,accurate,and that the following conditions have been satisfied: <br /> •....-The installer has menthe requin:, texts set forth in 23 CCR§2715.subdivmous(g)and(h).. <br /> • The underground storage tank, ariY PAY PiP?uS. and any secondary containuieni was installed according to applicable <br /> voluntary consensus standards ai l imymanufacturer's written installation instructions <br /> • All work listed in the manufacd:o :s installation cbeddist has been completed. <br /> • The installation has been inspect d and approved by the local agency,orif required by the local agency,inspected and certified <br /> by are 'stered profemonal en 'r wr h!3jRg education and experience with underground storage tan[c stem-installations. <br /> SIGNATURE Tk-W OROWNI AGENT DATE 2 ..484 �+. <br /> `J <br /> 1-33,1 <br /> CEIZ NAM tp ) �j - `as <br /> N OF CERTIFIER'S Eb?L.OYER.(DBtt - CER'lIFIER'S RELATIONSHIP TO TANK OWNER 0B9. <br /> Ek`2:T -OPERATOR <br /> [3 3.CONTRACTOR 4.PROPERTY OWNER <br /> < J � `""'" (] 5.OTHER AMOREM AGENT OF TANK OWNER <br /> IIP-CF UST_C Rev.=007),112. <br /> 007)=to wigw onidoec ori <br /> 2 'd zbE9I91160z1 suogoe4u00 AI a4113 jac :aT 61 01 Few <br />