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Oct 06 108 07:22a 2 67-5424 p.4 <br />VNIFUD PROGRAINI CONSOLEDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project.) <br />L FACILITY INFORMATION <br />FACILTCY ID # (.tgency Use Onty) <br />__T1 <br />_ <br />I <br />t.. <br />BUSINESS NAME (Say,eaFACMnYNAME orDSA-Doing BusinessAs) 3. <br />l 5 F Sty% I.tx7.3 C,0tAL7r _° F'I+$ £'i" <br />tai• <br />BUSINESS SITE ADDRESSITY <br />C ip4. <br />-*9r,a <br />I ttJ E. H Ai <br />e -e- <br />Ii. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that apply) 483a <br />WORK AUTHORIZED UNDER PERMIT 4831, <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date)- <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMEW <br />CSR Q® <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />2:nTHER <br />DESCRIPTION OF NVORK BEING CERTIFIED. 483e <br />a <br />c <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION ZOLV4M <br />CONTRACTOR LICENSE # Y— e7'41102. 492tL <br />ICC CERTIAICATIOIv # �. 4 <br />tCG 5313628 <br />�„{. zy � (aGoar!!o <br />s+etc AOi.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 pro&ssional en ' eer having education and ex 'enee with undEUound stow a tank system installations. <br />SIGNATURE.054ANK OWNER OR OWNER'S AGENT <br />DATE <br />PHONE 437. <br />/ <br />`'& 20 0 <br />( } <br />CERTIFIE AME (print) 40 <br />P.41 8 A C4.6y <br />CERTEFIEWSTITLE: 49& <br />t.. i►1 Awl 4rit2 `C t $TD Q <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 463 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER "S9. <br />6A &Ley <br />❑ L TANK OWNER ❑ 2. TANK OPERATOR <br />i <br />NTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />urcr UST -C - 1/2 Rev. (IV20M <br />