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May 05 10 02:26p Elite Contactors 12094616342 P • 1 <br /> i>FIEll PROGRAM A,FORM MAY 0 <br /> UNDERGROUND STORAdE TANK <br /> CERTIFICATION'OF Il�tSTALLATION!MODIFICATION <br /> 'All �,.. „m::�... .r»t'x, •rct.; <br /> FACS.J I'Y In rr(Ag=4Y USC'oMty} <br /> HIJSINESSNAtg easFneiiiTivamoYDBr!—IJaing.Xfvsi�aresilsJ <br /> 103 . GTS <br /> BCI5INI S5 SITE AD SS J T <br /> �T _ Y � <br /> +�+.t ,•-,a�ar.a- [+ gin <br /> • ° .. _ z i,... ir,. _" .. µ °s weary <br /> .. LZJNb PERNCIx' ' <br /> . • •• • ,. r4: -.•� �,. n- 4�SL <br /> WORK LT.tl�,li.�✓ <br /> TYPE'OF PROF GT(Chexk c1l char arty. (Numhar or DaOc) <br /> [a 1:TANK INSTALLATION OR REPLACEMENT. <br /> Q:Z PIPING 1NSTi1T I.ATION OR REPLACEMENTLCEN �f} <br /> [] 3.SLJW INSTALLATION OR ILEPL ACCT /t <br /> E]:4.(JNDEIt DISPENSER CONTAWNaN INSTALLATION OR REPLACEMEN7, �s <br /> DBSC12IPTJOP}OF WORK BEING(�ItTlFII;D: <br /> 130 <br /> ; <br /> ,.sir. ^sus <br /> „{ .,E.. <br /> OF C�.ONY�-RA�C,\I�.OR/ywHOOPEFCFF\0 <br /> FJhbINSTALLA-DONIMODIEICA17011 <br /> CUNTRAG7OR CB35 ICC•CERTMCATION'# — <br /> _. <br /> • <br /> { <br /> I certify that the'�nformation.provided herein is.#rue,accurata,cad that lite iollowtn�condifiun�s have been satisfied-. <br /> and:(h). <br /> T.h6 iastaBer has'mct#ire requirements set forth in 23 CGTL§Z715;s�drr�tslo�s 1(g) (��• <br /> • T11e .�aderground storagc tank, any prjm Y,p>IpIDg, Y d 3y <br /> ontaixxment was stns ed according to applicable <br /> _ vohmtary consensus staadarc and-aay lz nt[aer s b complete <br /> • iA31 wart listed itti the manufacturer's°instal . .mecird and certified <br /> ' 'the instanation.im bcm inspected and approved'by the Local agency,or:.re fired by the_local agene3',insp, <br /> .. tared rofwsional C ' ear having education and erience:whir and ovnd Stara tank. mstaIia6oas ,� <br /> DATE 4S° PfiONE <br /> SIGNAIiRiB OF TAMC OWNER.-OR O WNEIC'S AGENT <br /> .. � 416. <br /> 610 <br /> ' <br /> NAIvO OF CFaIZT]F1FR'S YJvR(DBA at8 :CER ONSFIIP TO TANKOWNER <br /> 'IIFIfR 5 p,FZ:ATi <br /> 1 <br /> - I TXtI!IK T}VZNER <br /> C1.'z'I1AA?IIC OPERATOR <br /> PROPEitTX OWNER , <br /> 1(] 'OTHERAUTHORIZEDAGENT-OF TANK QWI R ° <br /> JF3 <br /> r - <br /> �.�+ [IPCF TIS'I'-C Itev.(1 -11Z ww+rranidart-a`g . <br />