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Certification: <br />Tank Owner <br />I certify that the information submitted is accurate and complete to the best of my knowledge; that installation of tanks, piping, and <br />dispensers is according to Minn. R. ch. 7150.0100 and 7150.0205, including secondary containment of new and replacement tanks, <br />piping, and dispensers; and that all tanks and piping have release detection according to Minn. R. ch. 7150. 0300 to 7150.0340. <br />(For owners purchasing tanks after March 1, 2008, only) I certify that all tank operators, including lessees, have read this chapter <br />and have sufficient knowledge in the operation and maintenance of underground storage tank systems. <br />Name of owner or <br />owners authorized representative (print): <br />Title: Date: <br />Signature: <br />Tank Contractor <br />I certify that all work was performed as specified by the manufacturer's instructions; that all work was performed according to the <br />applicable codes of practice in Minn. R. ch. 7150.0205; that all work was performed according to applicable state and federal <br />regulations, including this chapter, and that I am in compliance with contractor certification requirements imposed by Minn. R. ch. 7105. <br />Licensed tank supervisor <br />on site during tank work (print): Ryan Smith <br />Title: Petroleum Installer <br />Signature: <br />Date: L a-S (( 1 <br />MPCA Supervisor #: 1165 <br />Licensed Tank contractor or <br />authorized representative (print): Pump & Meter Service, Inc. Cheryl Hein <br />Title: Construction Coordinator <br />Signature: <br />Date: <br />MPCA Contractor #: 607 <br />Site Assessor/Sampler <br />Minn. R. ch. 7150.0420 requires a site assessment be conducted at the removal of regulated USTs, at the closure in place of <br />regulated USTs, and if the product stored in the UST is changed from a regulated to non -regulated substance. Please complete the <br />following information to identify who conducted the site assessment. State Duty Officer: 1-800-422-0798 or 651-649-5451. <br />7 <br />Print name: ;r, /7 ? i (` i_`- Title: PI'"Q ec 71 G ! eit / 5 <br />Date: 3 " 2 / / <br />Company name: 19rialr7 J 74. G e")l 0L <br />II AO/ 449"i/ , e S <br />City: !/l /7 (�QO / -5' State: 44.4� V- Zip code: 5 3 k <br />// 3 r <br />Contact name: ' 5-2-- 7% 5 — �6C E-mail address: / f7e7# C fs aii /f77 ,740e , c �L <br />Mailing address: <br />www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />Page 3 of 5 <br />t-u5-04 • 6/21 / 13 <br />