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UNBUD'PROGRAM CONSOLIDATED FORM 1911,1171" loin. <br />UNDERGROUND STOP-4GF, TWK <br />CERTIFICATION OF INSTALLATION / MOI) IFICAT iWIRONMEM <br />(fine form per project) 7 CA <br />1. FACILI"T"Y INFORMATION <br />FACILITY ID # (Aywry Use Cbily) <br />BUSINESS NAME (awe as Faediry Name ew D84 Orzing Raaiwv As) 3. <br />BUSINESS SITE ADDRE.S8 <br />AN <br />I.L.I.N.$T,ALLATIONIMODIrl(CATION PROJECT DESCRIPTION <br />'TYPE OF PROJEar (C wk aLdmi amey) aui., wOKtc AVI-110RIZED UNDER PERMIT <br />(3 1. TANK INSTALLA71ON OR IkFP1,ACBA4FNT (Number or Date): <br />0 2- PIPING iNs-rALLATioN OR REKAcB4ENT <br />0 3. sump iNsTALLATioN OR REPLACEMENT ti <br />6 t C, <br />❑ 4. UNDER Er%SPPNSCP COI$T INSTALLATION OR REPLACEMENT <br />TIENT <br />OTHFR <br />DESCRIPTION OF WORK BEING CERTIFIED: <br />i <br />c r, C <br />U <br />H1. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PLUORMED 1NYrAILK1'ION 1 MODIFICATION <br />-E-LL Tc' a O:Anqcmc� - - <br />CONTRACTOR LICENSE# <br />IV.. CER TMCATION <br />I certify that the information provided herein is true, accurate, and that the fallowing 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 accordiQ to applicable <br />voluntary consensw standard.; and any manufammes written installation instructions. <br />• All work listed in the manufacho-cr's installation checklist has been completed. <br />installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />Y. a registered professional qpSineer having education and e "cocc with and Mround .qtorage tank SyStem installations. <br />VOV'TANK OWNER OR OWNIA'S A(;I-'.NT <br />DATL 414. <br />PHONE <br />Ub. <br />C�Eh-ni�-SNAME (0.1) <br />NAME OF CCRTIFIE4EL R'S EMPLOYIIR (D13A) <br />CEPTIFIEWS RLLATIONS1111' TO TANK OWNER 4n. <br />E-UTEM &AAD"',f)Q1-10t-3 <br />t) 1. TANK OWNM [] 2. TANK OPERATOR <br />"k3 -CONTRACTOR C] 4. pK0PrRTY OWNER <br />❑ 5. QT)IRR AlffHORMFIll AC;hNTOF-J-ANK01A✓'WR J <br />UPCF u8l-C Rev. (12/2007) - UZ WWWxRW0C&=T <br />2.d 2trC919*1602 OUI 5J0q0RJ%UQ3 Al a%T13 dee :21 91 92 Uer <br />