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Nov 16 09 12: 16p Elite TV Contactors 1209461PI42 p. 1 <br /> -UNUM PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND'STORAGE.TANK <br /> CERTIFICATION-OF INSTALLATION/MODIFICATION <br /> .(t�ngforni,geLprojecE). .... <br /> d.w -ds,*' '"K�-s�,. ' �« Yxs.,�:- art�',�+w.�sx�{a•4'i�g'�ti. ��ryjYS ,F �S.'ya�'� �3`,x <br /> [[y{{y5�5,1LJN�.t,.y{$.`t,.��•�'-.J�. •� 'a� �/¢�- "�A�� �p����i�:. �h���Ml ,.i..r .� ,'��'`4.y <br /> �a.�F-�t NCiY.'.•'.A�'+w\t��� q��.CY tf �':e1 "^:l�+d"S W:f:4sd'..-..,i. h.1.�n: t <br /> _ as <br /> FACILITY!A'#(dgenry Use QnlvJ <br /> B 1NF.SS NAME(Bance as F�eillry Name or DB.!—Doing Busixss ) - � <br /> BUSINESS SUE ADD <br /> -35+..•3.a mt4' . e G y O ;l:� .,h �mw. �.E R+-�+ 5•L N <br /> f...m ;c-vnv. kdsk ..ta4h.a+.,•K-+r --t 4S3 <br /> TYPE OF PROJECT(Check all thal a»nlvl <br /> 4�•.. woRKaUTHORIZE[)UNDER PERMIT 40b. <br /> ❑ I:TANK INSTALLATION ORREPLACENUNT (Namticr or Dace) ' <br /> Q,2.'PIPING INSTALLATION OR REPLACENg NI' <br /> SEIM?INSTALLATION OR REPLACEMENT <br /> ❑4:UNDER.DFSPENS£R COhTAII�TvfENT INSTALLATION OR REPLACFMIIv'? <br /> ❑"5.07HER { ` 483r- <br /> DESCRLPTION OF.WORK BEING CERTIFIED: ... <br /> IC <br /> p(i <br /> 4CuA &7Z <br /> � .: .* <br /> NOV 1 6 2009 <br /> ENVIRONIRi+NTAL <br /> KF_ALTH E)E?xgTMEW x <br /> � (k M11 �".6nxfPI'�WPx'9/ <br /> g � (rye ' <br /> "'" k 6�4b�> V�:: <br /> 1`61s'��e-..camT.vnne-:z;:•.�. ._a..-T<-•NM+rn - - -�� 4S?i <br /> 'NAME OF CONTRACTOR WHO PERFORMED IA'ST TION?MODE ICAITON <br /> 4M ICC. 492r- <br /> 4M <br /> CO CTOR 14CENSE# CER <br /> .-: .. ., - ._- Vi;Or.• rr..,e,o�rxe:ac..n�.,.* rra.+,.tn - °' U�. "f" <br /> _ _ <br /> I certify'that the.'informafion provided hereih iS irue,accurate,.and that the fb wN ing conons:have been satisfied:. . <br /> T7u installer has met the zequn;ements set forth m 23'CCR1... ;subdivisions(;)and(h): <br /> . The underground.storage tank, anY Prinsaiy piping, and any secondary contamment:was installed acg 20.applicable <br /> M..,-.:voluntary consensus standards arid.any;manufacturer's writteal inshaliatton insituotionsi - <br /> -- +. ..All work listed in the manufacturer's installation ch=1dist has been completed <br /> The lation has been inspected and.approved by'the.loce)aSen6y,or:ifrequired by the Iocal agency,inspected and certified <br /> ti a' tered professionalen ea Navin education and erience with under olmd storage tank stem Installations. 487. <br /> 5F r OF OWNER <br /> .OR OWNER'S AGENT. <br /> DATE PHONE <br /> 'S 4if CBt S TTTi.E. <br /> 0 .., <br /> el <br /> N OF CER I,OYER(DBA)>` CERT1FfER'S.RELATIO TOTANKOWNER <br /> NSIBP <br /> TAMC <br /> :., OPERATOR <br /> /�.�(yt 1.TANIC.OWNER <br /> 1 ❑ 3..00NTRACT0R ❑:4.-PROPERTY. <br /> - . „ . :. - :: - .❑.S: <br /> OTHER AU•ITiORIZED AGENT OF?ANK OWNER - <br /> L UrCr lSf-C Res(12rm" in.' _ :�^►.mid�° <br />