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Jun 20 13 05: 35a ElitAbmJV Contactors 1209 1 42 p. l <br /> -EC E <br /> I ' ED <br /> �.� <br /> UNIFIED PROGRAM CONSOLIDATED F035 of <br /> UNDERGROUND STORAGE TANK JUN 2 2 013 <br /> CER ICATION OF INSTALLATION/Y�.I� CATION <br /> SAnI JOAQUI�+b pro;-t.I <br /> FACILITY ID# <br /> (agency Use Only) <br /> BUS S NAME(s.as eatz¢raY—a rn®e <br /> BUSINESS SITE ADDRESS r sem• CITY . <br /> 'TYPE OF PROJECT(C 1=k 9 '4831 WORD.A THORIZED UNDER PERMIT4336. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT; (Numb w Date): <br /> ❑-2.PIPING MTAL.LAT1Of4 OR REPUCEMEN-k <br /> ® UMP.3.SINSTALLATION ORREPLACEMENT <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPL.AC&AENT <br /> i.OTHER <br /> DESCRIPTION OF WORK BEING CERTMED_ 4&90 <br /> Cl L <br /> t a ' <br /> NAME OF CONTRACTOR WHTA TION!MODIFICATION 4M <br /> �t�t <br /> 60A Z- <br /> C CTOR LICENSE# „ ° ICC CERTIFICATION# 4 <br /> *.certify that the:information'provided'wherein-is'tme;accurate;and-that the following's of ditions have been satisfied: <br /> • ' The installer has met the requirements set forth in 23 CCR§§2715,subdivisions(g)and th <br /> • <br /> The updergrougd storage tank, any primary piping, and any secondary'containment was.installed according to applicable <br /> voluntary consensus standardsand any man 's written-installation instn Uctions: <br /> A.l[work.listed.in themanufacturer's installation checklist has been completed, <br /> 'TIi�inslallatlon has en�in ted:.aaiil ""°.:roved b—fhe liical�.�"`en -di•if`__.`uired�bji'f k cal e'iic , 9iSs 'sled kdd certtfteii <br /> aPp y cY, I y l <br /> b tered Professional engineer havin education and experience with and ounc s :)rage tank system installations: <br /> SKIN OF TANK OWNER OR OWNER-S AGENT DATE 494• [PHONE 4e7. <br /> C ' IER'S N (print) 'CERTIF TME: _ 486. <br /> re <br /> NAME OF CERTHMRIS E&PLOYERLQBA 4ss CMTPWktRELATIONSEff:b TANK OWNER: 489` <br /> 1.TANK OWNER J.2.TANK OPERATOR <br /> 46. t. <br /> ��7!&.'�6t�• CONTRACTOR l k . <br /> PRO . <br /> p 5.OTHER AUTIIORIZBI:-E iEIJ'3'OF TANK OWNER . <br /> UPCF UST-C-rn Re®.{zxtznorj <br />