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07/31/2009 FRI 8:49 FAX 2094683433 SJC EHD <br />• <br />®001/002 <br />N gill <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKt I e3 2009 <br />/ MODIFICATIIN <br />CERTIFICATION OF INSTALLATION <br />I. FACILITY INFORMATION PERN!1. / <br />[FACILITY ID 4 (Agent), Use Only) <br />T-ri <br />I <br />I <br />1 1. <br />BUSINESS NAME. (Same as FACILITY NAM I'. or DIM - Doina Businass As) ). <br />�"-ot:,Ln4r,- C1 "b `7( <br />BUSINESS SITE ADDRESS f05• <br />5-7s' (L%L 0(410 `SIA. <br />CITY t°4' <br />S- <br />,-h-, <br />c o 1 <br />1I. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Chcck all that atmly) 4"a. <br />WORK AUTHORIZED UNDER PERMIT 497b <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Nwnber or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />S' R 005-7-7-7 <br />❑ 4. UNDER DISPENSER CONTAINMENTINSTALLX11ON OR REPLACEMENT <br />Q-5.OTI IFR <br />DESCRIPTION OF WORK BEING CERTIFIED: 4M <br />Re P WeA Vepd-et-- Qoc)+ yZotj_ 141 SPnSc n <br />q -}-e(rik- Annct(ar SfCkce <br />VP (200 F ✓ac uro SenSeJt� <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 492a <br />C e - n -i t -e I Pe---I-ir`n 1 e L VA n16LI n 4-C 0 Ct rA <br />CON'T'RACTOR LICENSE S 492u <br />49 19 T(- <br />TCC CFRT'UICATION H 482e' <br />5 3 i► S'�l <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 tanks stem installations. <br />��SIG ATURPOFTANKOWNE Olt OWNER'S AGENT <br />DATE 494. <br />-7/-61 /0? <br />PHONE 497. <br />(�Z- )1/&2-4/04-0 <br />CERT'IFIER'S NAME (Ixint)f 495 <br />r-) P6SkCL- c.r <br />L1I ee 4 <br />CERTIFIER'S Tl•II.E: 496. <br />r d <br />NAME or-- 198 <br />P <br />CERT'IFIER'SRF.LKHONSIIIPT'OTANKOWNER 492 <br />C � ✓,��u ' �D f <br />❑ L TANK OWNER ❑ 2. TANK OPERATOR <br />`� <br />E, 3. CONI RAC I'OR ❑ 4. PROPERTY OWNER <br />❑ 5.OTHER AUTI IORI%ED AGENT OF TANK OWNER <br />UPCP Us'r-C- 1/2 Rev. (12/2007) <br />