Laserfiche WebLink
A= Amk <br /> WhUD PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1. <br /> BUSINESS NAME(Same as FacilityName or DBA—Doing Business As) 3. <br /> SJ L L 0,1�e o P,At/0.,-J X4 <br /> BUSINESS SITE ADDRESS103. Cr <br /> I y 104. <br /> 130 6 426LrD1v AVE -s4 <br /> ` ,DcKf..0/J CA <br /> YSZ-vi <br /> H. INSTALLATION /MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT p <br /> El3.SUMP INSTALLATION OR REPLACEMENT +\ U v,6 7 qL) 03 hJa <br /> "Z D D 9 <br /> [� 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> (� <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> t)L)i5_40 F..AJLIEJ V M l 4,1.4)c L AK V61'F5 O/L f/IJ qy L baa <br /> G"P(-4-c j s 4--M ry M 0 D 15 �- y 9 LD --.2a 0 6 sr z,4 <br /> 'f E 'A4 SS-6,a Y,�-C-4L4,ry=j _Q C, y - � <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION �£�S� uYrb£N 482a. <br /> •J a51C 14ACyL a F V64761,E 6-x116819 lS6_5 <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# 482o. <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 aregistered professional engineer having education and a rience with underground storage tank system installations. <br /> S27E OF TANK OWNER OR OWNER'S AGENT DATE 494- PHONE 487. <br /> 0,3 /S a �6 )X67 <br /> FIER'S NAME(pried) CERTIFIER'S TITLE: <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> TTTIIT•TTCT/' T_.. /11RMT 1A �,�,�, �,,_�__�� <br />