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Oct 18 13 10: 47a Eli IV Contactors 12094 342 p. 2 <br /> REGEOV D <br /> ea <br /> :UNIFIED PROGRAM CONSOLIDATED I'( mM . <br /> UNDERGROUND STORAGE TANI; OCT 18 <br /> CERTMCA170N OF INSTALLATTON Iva 3DIFICATrO <br /> SAN AG9UBfV COUNTY <br /> FACILITY ID g(Agency Use Only) <br /> BUSINESS NA14E(Berme as FacitiryName or DBA—Doing Business As) 3. <br /> BUSINESS'SITEADDRESS ia3. Cply 104. <br /> 1153 T RIC <br /> n <br /> WAf 4. <br /> TYPE OF PROJECT(Check oo�1 aanlV) 413n .WOF X �VMOXMEO UNDER PERMIT 483n. <br /> Q L TANK INSTALLATION OR REPLACEMENT (Nm of or Date): <br /> n 2..PIPING.INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT, i <br /> 4.UNDER D CONTAINMENT INSTALLATION OR REPLAC EtENr <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERT•]FIIED: _ 4M <br /> D15P , :TC' �Q Ct t F . TFt F3 _ . Efl LEc� <br /> a CiE�:%6f\ cin o ; r ,t Ra <br /> •M <br /> tf .aid• - 'e tl@?mM Y' <br /> _ YS.S <br /> NAME OF CONTRACTOR WHO PERFORAIED INSTALLATION!MODIFICATION 482c <br /> it `s <br /> CONTRACTOR LICENSB#6&,ya '�' ICC'CERTIFICATION i zt n � 4�` <br /> 7neat the Information provided,herein is true,accurate,and that the following i ondidons bane been satisfied: <br /> staller has met the requirements set forth in 23 CCR§2715,subdivisions(g)and .3). <br /> The underground storage tank, any primary piping, and any secondary eontaiazn to t!was installed according to applicable <br /> voluntary consensus standards and any-manufacturer's written installation instruction.;. <br /> • All work listed in the manufacturer's•installation checklist hae been completed. <br /> • The installation has been'inspected aczd:approved by the local agency,or if required b_ the local agency,inspected and certified <br /> b a ie 'stared rofessio�I ha ' education and erience with and oLni storagetank stem installations. <br /> SIGNAT F TAN a R WNER'S AGENT DATE; 484• PHONE �• <br /> r ti Its 1::> t1 )91 t�33�1. <br /> CERT IS NAI >E 01 fnt) abs. CERTIFfER'STTYLE: _. �� <br /> NAME OF CERTIFIER-S EMPLOYER(DBA) 4U. CERTIFIER'S RELATION SI P.TO TANK OWNER �9. <br /> � / ❑ L TANK'OWNER, ®'2.`TANK OPERATOR <br /> 1 CONTRACTOR. ® 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORI2I;. AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12P-001)=112 WW W.anidoes org <br />