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Nov 18 10 09: 0Ga Elite Contactors 12094GIG342 p, 2
<br /> UNIFIED PROGRAM.CONSOLIDATED FORM NOV UNDERGROUND STORAGE TANK � 2010
<br /> CERTUICA7C'ION OF INSTALLATION/MODIF ICATIO, N,
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<br /> TYPE OF PROJECT.(Chi Qu that . WOtKAtTHORI?ED UNDER PERI.�= assnL
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<br /> L TAI1K INSI`ALLATION OR REPI.kMTE3VT.
<br /> (N»ber or Date): .
<br /> 02PIPINGINSTALLATION:ORREPLACEKIENT �i
<br /> 'Q'3.SUW INSTAL.LAZTQN OR REPL.'4CEb rr l�J
<br /> 4.UNDER DISPENSER CONTAII+I AENS II.'STALjA.TTON QFC ItEPLACII+tEh'P
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<br /> Cl2IP C10N
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<br /> OF CtJ TRACTOR WH I'ER'rORMEII STALLAT7 f IvIOD7fICATION 4U
<br /> Cq�,MRa.CTORLI N � ` . � 4sxe. ICC'CE1LTIF7 TIO # 482c.
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<br /> T certify that the tnforxriatioaproti'sded herein as.true,aCCUlatey and that the f6Howinn conditions have been satisfied: v
<br /> • Then ailer haszz+erifienrec3�uremenLs set forth,in 23 CCR§Z7I5;'subdzvisi�ms(g)and(h) ':
<br /> •: The under vend storage ice'anYPn Y.PSS+ and.any secondary cont 6nment:was installed' according to appEicable
<br /> -.._-:vofUnwrY-consensus-`standards and aaY.nzantr aCft='s wiittea:b3stalIatian=iIIstnictians
<br /> AII!work listed in the n'tanufacturies installation checklisthas been completed.
<br /> The instal3ation has'baen.insgecied and approved by the local agency,or°if n quired by thelocal agency, inspected and owed
<br /> b -re istercd Pmfessional engimcc-r.having education and E enence with uudeiaround storage tank stcm installations.
<br /> ..SIGNA OFTANK-OWNF.R'OR OVP,MA!S:AGENT a DpiTE 494, -PHONE 49
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<br /> NAI E OF GI;RTIFI£R'S EMPLOYER(DSAyt :'Ee, CI_'RTM ER'S RELATIONSHIP TO TANK OWNER 499.
<br /> D I T.�lidK OWNER Q ?'T O]'ERA7OR
<br /> '2535 Wk< 1 s� '� % 0 tyl ora^, Li 3.CONTRACCOR E�'a.PROPERTY r=cirY OWNER
<br /> Stock
<br /> MICT UST-C Rm(I ley 5205 - . . ;Y.liwxili ocsp
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