Laserfiche WebLink
,Nov •18.09 10:37a 209-367-5424 p.6 <br />UNIFWD PROGRAM CONSOW DATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION I MODIFICATION <br />(One form per project) <br />I. FACILITY INFORMATION <br />FACII.['lY 1Dk(AgencyUse Ontv) <br />iLL <br />BUSINESS NAME (Sanre os Facility Milne o+• DBA — Ooiwg l3xsfness dsJ 3. <br />CA LInAPA <br />BUSINESS SITE ADDRESS <br />C. -N <br />3 <br />II. INSTALLATION f MODIFICATION PROJECT DESCRIP'T'ION <br />'I•YI'EOC• PROJrCT (Clieckoff tlraranctrl 483L <br />WORK AMHORI7-rD UNDER PC:tMIT &t� <br />❑ L TANK INSTALLATION OR REPI.ACF.ME'Wl' <br />(Number or Date). <br />❑ ? PIPING INSrA1.LAT[ON OR REPLACEMENT <br />❑ 3. SUMP INSTAULATIONOft REPLACEMENT <br />OR REPLACEMENT <br />❑ . UNDER DISPENSE ItCONrAINM[i.NT INSTALLATION <br />6C <br />S. OT140t <br />IX-4CPRIIPTIONOFWORKBEING CERTIFIED: MR- <br />a f }} /� /y �,( l � <br />iJ�L/J /t �( 1��q`/ ( '� t i V U i `7'iVt1 t /" VJ� i <br />� rw 0,QW VA _ ��„� -F- <br />F-TiI. <br />111. CONTRACTOR INFORMATION <br />NAME OFjC' ONTRAC•T'OR W HO PEIVORMED INSTA€.LATION I MODIFICATION es=, <br />/PC, <br />CONTRACTOR LICENSE N 4M. <br />14CC CERTIFICATION N °b=` <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, and that the follbowing conditions have been satisfied: <br />® The instal ler has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secon&ry 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 installat_on checklist has beep completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />a registered professional e . 'neer• having education and ex elience with under round storage tank system iustaltations. <br />sic ' IEE OF TAMC OWNER OR OWNER'S AGENT <br />DATE 484• <br />1 PHONE 487• <br />IFIER'S NA : (punt) a85' <br />11E:ss,5 ,SCUM t5v <br />CERTIFIER'S TITLL•: 4& <br />R mAy 6 <br />NAME OF CE01FIER'S EMPLOYER (IDBA) 'm• <br />CERTIFIER'SRr;LATIONSMIPTOTANK OWNER 439• <br />!1, G� � � �� ��• S l� <br />l� <br />❑J 1. TANK OWNE[t ❑ 2. TANK OPERATOR <br />[LrJ 3. CONTRACTOR [14. PROPERTY OWNER <br />❑ 3.01tiER AUT7i01tI'LGD AGIWr OF TAN K OWNFdt <br />UPCF HIST -C Rev. (1212007)- u2 www.W*1oes0rg <br />