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f 02/25/2009 11:16 2094138 ENVIRONMENTAL HEALTH PAGE 02/03 <br /> r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(agency Use Only) <br /> . BUSINESS NAME(Some W FACIUTY NAME d DBA-Dnin$t3win••AR) 3. <br /> S. BUSINESS SITE ADDRESS 103• CITY104. <br /> 3 ZIV <br /> c�®tvo9 SToGilT6i✓, G� <br /> II. INSTALLATION I MODIFICATION PROJECT DZ SCR><,P'TION <br /> TYPE OF PROJECT(Chock all that avow) 4131 WORK AUTHORIZIED UN1)ER PERMIT 493n. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 0 INDER T)►SPENSER CONTAINMENT INSTALLAT1011 OR REPLACEMENT SQ L00 S Etc S1 <br /> VS.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 400 <br /> Ft2twm, _ <br /> GAS rO O.ESE c_ CNAaGE7 v-IsA%G f)ETC—C.'T'0a- QrvA\ <br /> Q C\ - t_0 ZC9C70 <br /> Sill O �'% O X N 3 t) 1 e 5 S T A L LE�) Pi E W 13��V m "'q6 %A A Q J r,. <br /> D `, 1L C,. , %A Q-S <br /> i\Za71�t= F ✓\ C7 A i U T>m C-S,E E i V Y'k. C—VN t.L1LC'^ J SG v <br /> ��'('✓t:'�l t,au21G I N s� d t2?l'/L. "'�4y+J L E•A\C �E i 1"c.,GT t.1'L_ T�S� �tJ R S. .� �..Y1. <br /> IIT. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO FERFORMED INSTALLATION/MODIFICATION aax, <br /> JE(21L Y'\A0Lr.20 1(T0t�—\ 51Z�1LQtC.1E ST('t1\0 v,m6 <br /> CONTRACTOR LICENSE# 482h JCC CERTIFICATION# 487c. <br /> a.. <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> e' <br /> 1 The installer has met the requirements set forth in 23 CCR§2715,subdivisions(gJ and(h), <br /> + 'The underground storage tank, anyprimary piping, and any secondary containment was in,staiied according to appiica;;lc <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> 1` + All work listed in the manufacturer's installation checklist has been completed, <br /> • The installation has been inspected and approved by the local agency,yr if required by the local agency,inspected and certified <br /> by a M 'stered professional engineer having education and ex erience With underground story a tanks tem installations. <br /> SIONATURE OF NK R OWNER'S AGENT DATE 4u. PHONE <br /> 25 - 0':j` <br /> CERTI'PTRIPS NAME pnimt) CERTIFTER'3 TITLE: 496. <br /> EAZ�G oG G�p�, 6A 5'020C Ur !GG S-2�fc<c ? ,y�v.c,,A,✓ <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 48R C,ERTTHER'S RELATIONSNI.P TO TANK OWNER M, <br /> ❑ 1.TANK OWNER <br /> 112.TANK OPERATOR <br /> S�TC3ClCTc�IIS SQL V 1 Cly S i A 1 Liv E Q ��6' ®'3�CONTRA.CTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTNORTZED AGENT OP TANK OWNER <br /> UPCF[ISI.0•1/2 <br /> Rev.(IUM7) <br /> z: <br />