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# (AgencyVse 0*) <br />BU� <br />BUSD <br />ri V01 11 JUL 0 o, <br />r r ..O <br />r�. s <br />joNDERGgqpNp e <br />A,. <br />orm <br />a <br />WiE' <br />_. 40, WORK. <br />TYPE OF PROJECT pj=k aJl ata &V <br />D I. TANKWS'TALLATIONORRETLACEMENT: :..(Num�e <br />D 2..? PINCi JNSTALLAnON"ORREPLACEMENT C, <br />D, 3. STJMP INSTALLATION OR REPLACENENT .. <br />D 4: UNDER DISPENSER: COAT.4IIZ M� T I�TSTALL.a.TIoN OR REPi.-tCFSVlF1�1T: <br />3: OTHER <br />— _ OMLRE-WORKZEUQG CERXllMX <br />Lo <br />J:7CGC Lt:�: <br />` NpA2E O �t PERFO�i2tJtED A' :Az,I.ATAa ./ � <br />CONTRACTOR LICENSE #. <br />ICC CERTMC/fwj�r1roJ <br />}[certify that the:xaformation gtwvided hererit is.trne, aceuzate, and that the inllowiug .t editions have been satisfied: <br />« The iBstaiTer Ixas metthe reQuirements sef forth in i'3 CCR §27i5;:subdavisious <br />Tba underground.stozage.'tsnk, arty"ptimary.PiF�• and.any secx►ndary con <br />tain>zea was installed according to applicable <br />valvntaty coigsestsas=standards and ant's written annstractio� <br />An warm listed is the manufacturer's installation cbe&list has begin GOMPleteci <br />• emoted and.: ved: the:.ocal or if required r� kze local aS .cYe inspected and certified <br />Tlte-insiallation:laas baa insp . $FPS bY" �' <br />a ' %ssional eai ineer:ltavin educafim and enence with u 3( ;tom tank system installaLioas. 497. <br />4sa. CiNE <br />SFON rUREOFT'.,AN OWNER OR OWNERSAGrENr <br />CERTIFIER'SyNAME <br />1(pr4 <br />S.TT1TE <br />CERTFt�mvs RELA.TIORT31 V TQTA�1iC'O�VPdBR <br />OF 7 1ER'S EMPLO (DBA} : <br />1. :. t--GONi1tACTOR <br />❑ ©, 2. TANK'OPERATOR <br />.. D 4 PROPERTY OWNER <br />.ri fiORL� UNDER PERMIT 4m . <br />r Dstc): <br />f <br />- <br />OTBER:AUTHORI7M eifiEA�T OFiANI:OWNEIt <br />. stwvvanidecs.or� <br />VpCFTiST-C Bev. (1=807)=112 <br />4M <br />ICC CERTMC/fwj�r1roJ <br />}[certify that the:xaformation gtwvided hererit is.trne, aceuzate, and that the inllowiug .t editions have been satisfied: <br />« The iBstaiTer Ixas metthe reQuirements sef forth in i'3 CCR §27i5;:subdavisious <br />Tba underground.stozage.'tsnk, arty"ptimary.PiF�• and.any secx►ndary con <br />tain>zea was installed according to applicable <br />valvntaty coigsestsas=standards and ant's written annstractio� <br />An warm listed is the manufacturer's installation cbe&list has begin GOMPleteci <br />• emoted and.: ved: the:.ocal or if required r� kze local aS .cYe inspected and certified <br />Tlte-insiallation:laas baa insp . $FPS bY" �' <br />a ' %ssional eai ineer:ltavin educafim and enence with u 3( ;tom tank system installaLioas. 497. <br />4sa. CiNE <br />SFON rUREOFT'.,AN OWNER OR OWNERSAGrENr <br />CERTIFIER'SyNAME <br />1(pr4 <br />S.TT1TE <br />CERTFt�mvs RELA.TIORT31 V TQTA�1iC'O�VPdBR <br />OF 7 1ER'S EMPLO (DBA} : <br />1. :. t--GONi1tACTOR <br />❑ ©, 2. TANK'OPERATOR <br />.. D 4 PROPERTY OWNER <br />- <br />OTBER:AUTHORI7M eifiEA�T OFiANI:OWNEIt <br />. stwvvanidecs.or� <br />VpCFTiST-C Bev. (1=807)=112 <br />