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06/29/2012 14:26 2094683A,13 SJC EHD UNIT 3 PAGE 02/02 <br />it is <br />10 TIOM I 1L K901% i'Ll 197 <br />Romw <br />IRA RRIN MI LZA1,C4.1 <br />Facility I-acliny <br />Name L�2�,A_� Address L 15: Wa4gyIL-)C) Sibck7f6A <br />Title <br />"0. "�' C' <br />_ C�eo� <br />Facilityt� / !F� C_ <br />Contact <br />Contractor <br />Name <br />o 87 fill sump <br />Contractor <br />Address <br />9- 5V) 15 uj�-')M Pr S +V 14& <br />CAL ruse <br />nurnber <br />LClassC <br />00 <br />6_ <br />o diesel piping sump <br />onToo# ' <br />FAphontC 10 A?, <br />_? : - T <br />L7 " <br />Inaurer <br />e -x P1 0 re V_ <br />Work <br />comp. # I <br />W L 5- 0 0 312 <br />JCC Teo)) <br />LA <br />Exp. Date <br />10 rte- 5146%qkk <br />ICC Installer <br />c 89 -octane UST <br />Exp. Date <br />o diesel UST <br />Indicate below type of work to be performed. Check all that apply. <br />14 Sensor replacemeDt <br />Modeli 'LA L4n LS <br />* 87 piping sump <br />o 87 fill sump <br />* 89 piping sump <br />0 89 fill SUMP <br />*91 piping sump <br />0 91 fill sump <br />o diesel piping sump <br />m diesel fill sump <br />o dispenser 1/2 <br />n dispenser 3/4 <br />o dispenser 516 <br />o dispenser 7/8 <br />o other: <br />0 Leak detector replacement <br />Model: <br />o 87 -octane UST o 89 -octane LIST <br />o 91 -octane LIST o diesel LIST <br />o other: <br />0 Spill container replacement (not direct bury) <br />Model: <br />o 87 -octane UST o 89 -octane UST <br />ci 91 -octane UST n diesel LIST <br />o other: <br />0 Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade, <br />Dispenser: <br />Grade: <br />1:1 Sensor replacement <br />Model <br />* 87 piping sump <br />r3 87 fill sump <br />* 89 piping sump <br />0 89 fill sump <br />* 91 piping sump <br />o 91 fill sump <br />* diesel piping sump <br />o diesel fill sump <br />* dispenser 1/2 <br />o dispenser 3/4 <br />* dispenser 5/6 <br />o dispenser 7/8 <br />* other: <br />0 Leak detector replacement <br />Model: <br />o 87 -octane UST <br />c 89 -octane UST <br />o 91 -octane UST <br />o diesel UST <br />o other: <br />0 Spill container replacement (not direct bury) <br />Model: <br />* 87 -octane UST <br />o 89 -octane UST <br />* 91 -octane LIST <br />o diesel LIST <br />o other: <br />0 Automatic tank gauge (ATG) replacement <br />Model: <br />o 87 -octane UST o 89 -octane UST <br />o 91 -octane LIST o diesel UST <br />o other: <br />*This application applies only during routine inspections or monitoring certifications. <br />t�Acw �ted By,/, <br />PE: 2308 1 SC: 098 ignL --_) 0. /J, (A I Date: _5,AQ_ <br />signed 5 29. I <br />