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.Apr 24 13 08:57a <br />I <br />r <br />mi <br />El I IV Contactors <br />12094&16342 p.2 <br />UNDERGROUND STORAGE TAN K <br />CF,RTIFICATION OF INSTALLATION/ P [ODIFICATION <br />(0- form per pmjc�ct) <br />(Sema ft FAC)Lrry NAA�I'WDBA — Dig 13mb. A,) <br />TYPE OF PROJECT (Check all ttjq gyo <br />0 I. TANK INSTALLATION OR REPLACEMENT; <br />0.2. PIPING INSTALLATION OR REPLACEMENi <br />Q 3. SUMP INSTALLATION OKMLAO RMNT <br />El 4. UNDER DISPENSER CONTADMIENT MTALLAT70N OR REPLACEMENT <br />71 S. OTIMR <br />-Mcl - , 1M;9�` An Qkv-u - fhtj <br />-VC Cj, 1) r0&J QCPV-n+ -V- i <br />Y1 5V LO bL�-C& <br />41 22-t5 Md Wt cLficr Qtfrv-1'\t, 0,ab P", i Z6 -b (x-M-nec6 <br />Cj-) <br />�bi ilu, fn <br />SMC <br />10C CERTIFICATION # <br />-1--tert*-Mat-&einformation*--provided -herein- iv fme� -nec <br />u"tei72-nd-thAt-the4o]lowing-l-olilitions.hav&,been-satisfied:- <br />• Tbe installahas met the. requirements set forth. in 23 CCR §2715; subdivisions (g) and 1i <br />• The undeigro' <br />und storage tank, -any p#pa.ry ;pjping,. anO, any secondary *cOnt2inme; it ;fw installed . according to applicable <br />Vo untimy consensusstandards an a any mann Curers va7ff= installW <br />on Instructions. <br />en -sat"' ed <br />'cording to applicable <br />• All.work listed in the mgiufhcturl�s installation checklist has been completed. - <br />Th installation has been <br />inspected and app e: ert.f <br />roved by the-16cid ag local agency, inspected an e <br />b ency, or� if. required by t d <br />re isteTed th . :d certiffe <br />n' <br />s�ional ell I infer ha education and experience W) dergrourll s I ons <br />n installations. <br />SIGN -a?, e tank stex7 <br />0 --TA COWNV-R.6�.�rwm S�AUEW PHONE <br />481, <br />'A72-2 <br />IFR'S NA�N(pm <br />CERTHUR'S TITLE. 496, <br />-i; OF CERYffi)Bk,S-EbdkUyER (bbq RkCATf ONSH —P C."Tkw ij .499. <br />C f 1f t CIC Iv CIT0 I. TANK OWNER 12. TA. NK OpEpATOR <br />.0 3. CONTRACTOR' <br />I I 4.--?R0PERTY-6WNER <br />S. OTHER_ <br />AVTHORIM' A tWOFTANKOW-NER <br />.... . .. . ....... <br />VPCFTjSr-C-1/i <br />