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Oct' 19 12 05: 54a E1it IV Contactors 120946342 p. 2 <br /> UNIMI)PROGRAM CONSOLIDATED F( EM <br /> UNDERGROUND STORAGE TANS <br /> CERTIFICATION OF INSTALLATION 1.10 ;)DIEICAT'ION <br /> (One form.per prod eq).. . <br /> FAaLr1`Y ID#(Agency <br /> BUSINESS NAME(Same w Faddy Nome or DBA-Dafng Business As) 3- <br /> � ha <br /> BUSINESS SffE ADD�R•ESS �a;. CITY L <br /> R. C' iGYa.•Yw.A 4W+h.•Y•m nP' F''1kT2 '-�" At' <br /> ;..d: _d?e a. .a„iw w, xr^r .rt er 7e.. '✓ Z.', f <br /> TYPE OF PROJECT(Check Off th4f annlvl 463n Wo.-.K k UTHORu ED UNDER PERMIT 463h. <br /> 0 1.TANK INSTALLATION OR REPLACEMIENT. (Nw..t •or Date); <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> n 3.SUMP INSTALLATION OR REPLACEMENT / <br /> 4.UNDER DismsER CONTA 4mma INSTALLATION OR REPLACEMENT ° <br /> S.OTFIER _ <br /> DESCR7n0N OF WORK BEING CERTIFIED: <br /> W � Cc�ll�d cx h�i A rdcrkb u i5 oo 51 .'e � nit L�.n5 � '��. . <br /> 1(ctc; t� 5 i� <br /> Kgtcc d �IUC> hum u'l ; TIV r✓i1 Sat-) ru c.L2 'li-1 5 4 fil(cay1z, <br /> Teb ed wC x-O5L�. a -IL 'p <br /> �r,c�:tc�.s' •�c•!t ��„�, Pmt' � .�,,, !�r � �-' <br /> v!:'r�L"}�pu�a::.:"—.''r$'�s`"..:it� yxran, _ �'l7 rx ��}:4^:.,,J;.•t!'I�F.'",'^..,�; r.. <br /> NAME OF CONTRACTOR WHO PERFORMED}NSTALLATION!MODIFICATION <br /> CONTRACTOR LICENSE# 4M. FCC'CERTIFICATION� 4M <br /> I certify that the information provided herein is true,accurate,and that the following;i Pnditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)an i 1). <br /> • The underground storage tank, any Primary piping, and any secondary containae t was installed according to applicable <br /> voluntary consensus standards and any manufheturer's written installation instructions. <br /> • All work listed in the manufuicturer'S installation checidist has been completed. <br /> • The instal ation.has been inspected and approved by the Local agency,or if required 3l the local agency,inspected and certified <br /> by a stered proflessionalepgInew hLv:m&educatiom and a rience with undergrouni :;to a tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 464• PRONE 481 <br /> CSS tC-ick- V2- <br /> CERTIFIER'S N 1 CERTIM ER'S.TITLE: 48d. <br /> 497 MANS OF (TMER'S EMPLOYER(DHA) �' C$RTfFIEEC'S RELATTON;F P TO TANK OWNER <br /> t �TJ 13L I � �(I?��5 t� (] L TANK OWNER (] ,TANK-OPERATOR <br /> 3.CONTRACTOR t] 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZ Q LGE,NI'OF TANK OWNER <br /> iz UPCF UST-C Rev.(12a000 -1R mvw.unidocsarg <br />