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t <br /> Feb 23 09 11 : 27a Eli 6 Iv Contractors Inc 208461 42 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORA(;L, TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per prqicct) <br /> 1. FACrLITY,,YNFORMATION <br /> FACILITY 1D <br /> BUSINESS NAME 67amr-aslitcilin'Na—,vo-L)Vyl-Dmr�Tzfimfinam.44 7. <br /> 103, Crry F477 <br /> C� <br /> IL INSTALLATION MODIFICATION PROJECT DESCRIPTION <br /> 11ORIZILD UNDER flj�jw 1] <br /> TYPJ�, PROJECT(Clieck g1l that 481, woim <br /> FEE111.TANK INSTALLATION OR REPLACLMLNT (Number at-Datc): <br /> _ "j <br /> El 2,]PIPING INSTALLATION OR REPLACPMJ.'NT <br /> C E3 <br /> 3.SUMP INSTALLATION OX R.LPLAL7F?v1V,'N-I- <br /> PE❑ <br /> ] 4.UNDER DISPENSCR CONTAINMENT INSTALLATION OR IULPLACEWNT <br /> .,;CRVr1ON 01,WORK BI"ING CERTIVIFI); 48:1.. <br /> Lahu a-% U 0C s <br /> 0 C�5d Z)u ml <br /> � � b T P <br /> III. CONTRACtbR INFORMATION <br /> NAME 01,C6NTKACrj1k_W1-JOVLRi;ORME,0 INSTALLAT)ON MODIFICATION <br /> CONTRACTOR LICE NSE# !ON# 4HN: <br /> IV. CERTIFICATION <br /> 7millI certify that the information provided herein is true,accurate,and that the following collditiuns have been salislied: <br /> if <br /> "I'- <br /> er liar met the requirements SCt forth in 23 CCR,�,2715.subdivisions(g,)ur' (h). <br /> • The in d <br /> • The <br /> c underground Storage tank, any primary piping, and any secondury containment was installed atxurding to ipplicable <br /> voluntary Consensus Standards and any manufacturcr'S Written instal lation instructions. <br /> • All work listed in the manufacturer's inSt2lbitiun check-ti.m.has been complord. <br /> • The installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> r �istere(j qofcss;onal en'incer having educ-n(ion and experience with under,Tound Stora-e ttin[c_system installations. <br /> 11 or TANK OWN'IL'K OR OWNEWS A(jLN7 DATE 494 1 PHONE _ZY- <br /> (26ck )�i 4 16-:5571 <br /> 1 <br /> CrIt' Iius 1ML(print) <br /> CERTIPIL-it'S TITLE: <br /> - Red hnW(j1 <br /> NIMP OF(7,F-X711`LER'S EMPLOYER(D3A) CERTIFIER'S R1iLA*1'JON!JHJJ1 TO TANK OWNER <br /> Ekrj a El 1.TANK OWNLA El 2.TANKOPERAT01t <br /> 2`J36 0S _' Sa.CON*vRACTOR [:1 4.PROPERTY OW NER <br /> ,3bC_dCn - 6�b'ZC5 El S.OTHLR AUTHORIZED AGENT or TANK OWNER <br /> UPCr UST-C Rev.(12120()7)-112 www-unWomorg <br />