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UNIFIED?ROGR4M.CONTSOLEDATED FORM <br /> i�iiaa 1 A*��/-�1jNDEjRGR0.bNb ST-0RA cJ✓xkNT1CC `j�]-�� 712��� ` <br /> CEI?-', _ITIC.�'S.1.C4f'N l.�:l.` INSTALLATION/ .l0'AQ3.I'.fik ICkki�.�,�'i <br /> 1 <br /> .. ' : . •`. : ..(Qne fos�n•perpzojEct).:._:..• <br /> se <br /> � aW*r <br /> sw$viex�'%E¢s+tyy ia� �K?i �.kr?c10111 <br /> 1 r <br /> x r�xa qF v,e�tcrsr rr»�4 Dais r +c �vti n,.. <br /> FAM- ID I(Agency Use Ohl;I -- <br /> "•BU SN-AM6(Seheeesfry �orheorDBA-DoingBusihesAsJ - 3'"' <br /> BUSTNESS•SMADD S. eoa. <br /> kz <br /> . ... •�°P, e4 r F�TPr,I• wa.rtmrtc.tx'eok�K+i ;: 'r,/�'-��•aRim4tM iy :N�is9Gu^ri.-iFta:tzTh '""[b1^.Ry! .G 3'9t-�T CU�:4 <br /> ..rt' ..L• �'C ! :.Grv'M•m.aCx1Hi i _..x4.a.._. ..r.v 9w .. v. •,y,/v_ <br /> ;3YPE OFPROJECT(Check ihaf.r.a di.l. :.: .: 4s3s.• WORKAUMOR72 D UNDER-PERMEr- .as3b..: <br /> :..:. .:l3•1.TAilM-]NSTAL1AnGNORpJ TACEMENT: (Nz>inberorTlaie)r <br /> L-[123.:PIPING JNSTALLATION OW.1 R'-ACUMN7 . <br /> SUMP INSTALLATION OR RE L iXENl� <br /> ::1];4:UNDERDISPENSER'CONTf�7 %1-�TTIN$TALLA7•fONORTZEPLAC HENT- <br /> ' :'' '�'3:07J:iER:• .. <br /> --.�:-:---�ESGRIP.TJOA'.OF..SYOR�EINCd�5 3::F�D:—.---------___.--= - - - —• --- -- ---...---- --- _�aS�c_.�... <br /> ki <br /> f bq� l 9 . <br /> & s�r+4crsrt mmr�u awav� ?!esi <br /> xu+. �3R::.2.;...: ��jy.. •�`n'. <br /> j . sAia�:U6 a "F�w.daxai� ,V.ax.x- <br /> NAME.OF O � C �jq�D ' N/Jv10DIFICATION <br /> COIv CIOR.LICIIVS 482b. ICC:CERTIFJCATION3Y 4Qi <br /> r. <br /> '�tg,. "' `'cL.u. �cr ux.� 'Ey�y 47 �a L••s�us:rx t��a»a_ a •rz 4 z�*� fc-r�,9-a,.r 1•+.--.�"�° +"" c�x�w.,,,,„ ,v.+w <br /> '�`y�tbt �"�.'��'§. "`�4wy, r,;.••.-.K � a�}��r +W t-C '•�.g�'f:.��' <br /> ' h+? Y,� .v�"� -:_. _.a Nau�r” � �o!� i�M+a�{:�:,.w::.•Mir` ��Y .�-Q.d _.•_.•�^fi�: �v_•'�ti+i" .}iti��''k.,,�: <br /> .X certify that the hilori iation•proi d..d herein is,true,accurate,and that the following conditions.have been satisfied: <br /> ^ TheansLslIer ltas�et-the-regphi averts set forth,in 23 CCR 271 .snbdiv ions j ana' ) <br /> . : The underground:storage tank airy primaiy piping,:and any,.secondary contal=ic :'AIRS,installed'according to,applicable <br /> =:voh�ntary consensus�taudards-a d a Yxianufacturees written instaIlarionynstiuctions:: <br /> :• :;. .: <br /> ..All work listed in the iix nufactt 's•installation eheeidisf'�has lyten.compleiod•: , <br /> • .. The instailation:has'been aiispe: :d cud.approvediy the_Jocat•agency,`:or'if•IY quireal.by.the]Deer]agency,inspected and certified <br /> b. aTe sterecl ofessional en i eeM.havin educa4mand E erience with and onndstoratie tank 'stem-installations. <br /> _$IGNA OF TANK OWN�I2 OR M,,' Z'S-AGENT'.: arc yHONE. 4az <br /> /:�:y �.� .. <br /> _ <br /> ER� cE�cTrai° <br /> :.. <br /> of ERTIFIt]2's E1VJt'�Ol'BR{DB=1 CER. oNsr38:To.iA�rlc'owNSR <br /> t ' .0'"T':.A?\T K OR'I�C':It'' CL'`?'T}L1�TP:OPERA3DR <br /> •4i6. 489. . <br /> /I <br /> 0B..CONTRf�ClOR .; 0'.4.PROPERTY OWNER <br /> J"j I: 1 17�/ 13:5.OTMMALT MOR=AGENT OF TiST1E:Ov,?1E}t <br /> _';w. .NPCF:TIS.T-C Itev.(I22i10�=9Q: ...'.irww.iiu doa.Orr:. .. .. - .. <br /> T 'd 6 9 T 9 6 0 a T J0-40e-u00 nI a-41 13 eSb :60 TT TT .add <br />