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MEN <br /> Ftb 13, 09 08: 18a Elite0v Contractors Inc 2094642 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project). <br /> i'. .RACI'LITx,.P,YF'ORMATION ,. . <br /> FACILITY IDNA <br /> #(Amy Var Only) - <br /> 1.. <br /> HU SS NAME(.Sanrr as/'aa'g Name orR-thing Banal. Asj ]... <br /> HU. NESS 51 EADmtL'•`• lei Gr, <br /> hy <br /> I1_..INSTAI CATION/ DIFICATIO,N PROJECT AESCRIP�lON. <br /> TYPH OF PRO)F•C'f(CLeckall Memel u 'O7WORKAUTHORJZFr)UNk&It PERMIT aJe. <br /> 0 1.TANK INSTALLATION OR REPLACEMENT Iln4,); <br /> 0 2.PIPING INSTALLATION OR RPPLACrdALNT0 7.SUMP INSTALLATION Olt REPLACEMENT /V��! Q-7 2, <br /> 4.UNDER DISPLNSFR CONTAINMF.NT INSTALLATION OR RF,PLACEMENT <br /> S,OTHERf l ll <br /> VES CRn71014 OF WOIABMN( CLRfL7ED: •' <br /> rUfl .1 <br /> okmA <br /> M. CONTRACTOR TNT ©N ` , ... ..... <br /> NAME OF <br /> #�A) OR W R LU INSTA 'IJUN/MODLJCATION 4m <br /> CEM u'v' ICC'CERTfIICAT10N# ti+u <br /> Iv. c15 Tkt r oN <br /> I certify that the information provided herein is true,accurate,and that the following conditions have boen satisfied: ' <br /> • The installer has met the requirements set forth in 23 CCF§2715,subdivisions(b)and(h). <br /> • The underground storage tank, any primary, piping, and any secondary containmcnt was installed according to applicable <br /> voluntary cOmmus Mindards and any marmfaelura!s written installation instructions. <br /> • All work listed in the manufacturers installation checklist has been completed. <br /> • The installation has been inspected and approved by die local agency,or if required by the local agency,inspected and certified <br /> a ie 'Stercd mfcssional on ' cer having education and ex cricnce with undo round Stora tank Wstem installations. <br /> SIGN%TU REOPT'ANKOWNEROROWN1 -,s OLNT DATENN. PHONL' egg, <br /> (20'x ) <br /> CLI{fIF1ER'S NAME( rio!) _ °%$. CERT)r, 'S TITLE: <br /> F-E-D <br /> NAME OF F.RTIFIER•S EMP YER(DHA) UK CERTIFLLR'S RELA'1tUNSHW TANK OWNER 4" <br /> TANK OWNER <br /> •� ��� �� 0 Z.TANK OPERATOR <br /> -OONTRACFOR ❑ 4.PROPFi(TY OWNER <br /> /© S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> It"UST-C Rev.(/X2007)-rn_ www.unuh,cs.org <br />