Laserfiche WebLink
Sep 14 11 01 : 38p Eli IV Contactors 120946' 342 p, 2 <br /> UNNIEDPROGRAM-CONSOLIDATED FORM <br /> U11TI)ERGRL7FJAD STOpkGE TAIL . <br /> CERTIl ICATION OI+ INSTA LLATt ION./ ri[!3]DIFICA.TION <br /> - �.(One;fo�.pecproject)... <br /> BUSTRESSNAME(Smm.asFaeiliryNam orDRA—Doing Busm=Ar) <br /> BUS L?VESSSITE AODPESS <br /> TYPE OF OF PROJECT(Cher E all that annluy T ! r I ri x � a <br /> >� I.TANK IA'STALLATTON OR REPLACEMENT �a WO U 14UTHORIZED"UNDER PERMIT v 401b. <br /> Q 2.PIPING NSTAL�LATION OR REPLACEMENT t of 11^''' t orDate). <br /> �1� <br /> Q 3:Mve.INSTAL7 AT70N ORREPL:A�ENIf~hT C <br /> II 4:UNDER DISFENSERCONTA WjVT INSTALLATION OR RF_FLACE MqT �"� 6,5 2-5 C <br /> Q 5.OTHER <br /> DESTlON OF tid�O2ZR BEING C£RT7ECr�: > - <br /> -- -- 4m <br /> C 1b WC 51E.Pam6cx, <br /> �E Zfi �L �,61Y� e �l u c Ell l; C.T t 04 �� �- S <br /> e�ESt1 e�c� a �e;t�lSfic�lled. <br /> giNAME OF CONTRACTOR WHO PyBtFO -- <br /> RIvIHDyh^TS�TALLAT�IyOIt+T/MOD.�MION <br /> CONTRACIOR'LICENSE# <br /> ICC CERTIFICATION# Qlm <br /> Co c, <br /> _ A <br /> I certtlfyy.that the information provided herein is.true,accurate,and"that the f'ol'io <br /> wmg coup r.dons have been satisfied: <br /> • Theinstaller has met the iequuements <br /> • The underground storage set forth in 23 CCR§M5,subdivisions.(g)and(h). <br /> - - <br /> tank, any pranary P�P�g, mid azi s"r . <br /> vohmtary.consensus standards and y dart':containment v t> installed according to applicable <br /> any manufacturer's writteninstallation instructions, <br /> • AU.work listed in:themari 'S.iastaiiation:.ehecldisthas been completed. <br /> • The installation has been inspected and approved'by the IocaIby agency,or�if ed <br /> a i e eyed rofessional-en�meer hav- education and erience'7th reiindr o d't o; t= agency,�e and certified <br /> SI C1F TAMC OWNER OR OWNER'S AGENT DATE <br /> — ua. jnstalMons. , <br /> PHONE 4b7. <br /> cERT7FJER:SST1LL8i <br /> NAME OF CERTHMR'S EWLOY£R.(DBA) <br /> CERTIFIER'SREC:ATIONSIMI c -I NK OWNER 489. <br /> --17 I.TkwN 6wnrER. rANtc-OPERATOR <br /> coraiRAcroR L :PROPERTI''owNEFt <br /> ® 5-OTHER AtFiTiOR[ZED'AG E I'OF TANI:'OS1VI>IER <br /> UMF DST-C Rev:(z?fl00lj._I2 <br /> www.tmidt+ss org <br />