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Jul 10 02 09:47a Elite Iv Contractors Inc 2094616342 <br />P.1 <br />XJ: u43I AJ l_11k.l;LvlN /.,1V1UDIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check -all that unnly) WORK AUTHORIZED UNDER PERMIT axs� ossa <br />❑ I. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT �� �j % ry <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT C1 GJ <br />715. OTHER <br />1 � %RShctrl � v�•�..- <br />�--k?' <br />Wv <br />IIL CONTRACTOR IN•FORMATION <br />NAME OF n aF_T ;FV n of rnn <br />LICENSE # <br />ICC CERTIFICATION # <br />777777; <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's installation checklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a registered professional engineer having education and ex erience with underground storaa tank stem installations. <br />SIGNAT OF TANK O R OR OWNER'S AGENT DATE 44• PHONE 487. <br />CERTIF[ER'S (print) 485' 496• <br />NAME OF CERTIPIER'S EM LOYER (DBA) 41;8.CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />` •� <br />Ax, <br />151. <br />.CONTRACTOR 0 4. PROPERTY OWNER <br />OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.uaidocs.org <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />t. FACTTTY INFORMATIQN <br />FACILITY 1D # (Agency Use Onlv) <br />L <br />BUSPYESSIYAA�E(Sa ! Facility Name or DBA—Doi Businesc,gsJ 3 <br />�L% <br />BINESSSITE[ADD /SS� p .+ los. <br />!f <br />CITY �104,1 <br />XJ: u43I AJ l_11k.l;LvlN /.,1V1UDIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check -all that unnly) WORK AUTHORIZED UNDER PERMIT axs� ossa <br />❑ I. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT �� �j % ry <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT C1 GJ <br />715. OTHER <br />1 � %RShctrl � v�•�..- <br />�--k?' <br />Wv <br />IIL CONTRACTOR IN•FORMATION <br />NAME OF n aF_T ;FV n of rnn <br />LICENSE # <br />ICC CERTIFICATION # <br />777777; <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's installation checklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a registered professional engineer having education and ex erience with underground storaa tank stem installations. <br />SIGNAT OF TANK O R OR OWNER'S AGENT DATE 44• PHONE 487. <br />CERTIF[ER'S (print) 485' 496• <br />NAME OF CERTIPIER'S EM LOYER (DBA) 41;8.CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />` •� <br />Ax, <br />151. <br />.CONTRACTOR 0 4. PROPERTY OWNER <br />OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.uaidocs.org <br />