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Aug 23 13 09: 45a EliteIV Contactors 120946342 RE,p�i�L 1 E® <br /> ,. : 1IVV__ <br /> EIV <br /> ED <br /> PROGRAM CONSOLIDATED FOIIA <br /> UNDERGROUND STORAGE TANK �pNMENTq <br /> CERTIFICATION OF INSTALLATION I MO: IIFICA H NMENT <br /> (One o m p <br /> gWAT <br /> L;BACILITYINFORMATION — <br /> FACILITY ID 4(Agency We Onty <br /> BUSTSS NAME(Ssm =FAMM NAMEm DBA—Dm&Blm, M) <br /> BUSINESS SITE DDRESS WI. CITY )a' <br /> 11. INS ALLATION/MODIFICATION PRO JEC DE34 REMO <br /> TYPE OF PROJECT(Check all thit mply) 461" WORK.\I I'HORIZEDUNDERPERMIT 4836' <br /> ❑ 1.TANK INSTALLA77ON OR REPLACEMENT (Numb:r, Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT • ry <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT I(1 <br /> S.OTHER _ . <br /> DESCRIPTION OF WORK <br /> RRK ByEDJGCER'`IF1ED- a83c <br /> �U1 Lf i <br /> rl I I..�J 'T��' l5t 4xl.fLl� JC%TTLCY.LYL' c� I.Ji k. it : .f/ <br /> �FIJ��I�uCI Ueecizi' '��=� sc:nscr ,�-fly; til-��Iltx;n� , L�`I��w3�cr;��u - <br /> 1 Fiat cmenf 0� S7 Fe Pc+re 1V15 vq{; <br /> 1Ici1 P�; i U ' fir �f '�n�� fo��i� �1ity <br /> III COiNTRACTORINFORMATION ": <br /> _. <br /> NAME OF CONTRACTOR WHOPERFO INSTA ATIONl MODIFICATION <br /> ,l <br /> _ <br /> CONTRACTOR LICENSE g 4626' ICC CERTIFICATION k_ 462c <br /> TV-CERTXRICATION <br /> I certify that the information provided herein is true,accurate,and that the following c nditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and 1 Q. <br /> • The underground storage tank, any primary piping, and any secondary containO : 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 'D: the local agency, inspected and certified <br /> a_re <br /> registered professional en ineer Navin education and experience with undergroun, storage tanks stem installations. <br /> 37 <br /> 5IGNATUREO OWNER . R'S AGENT DATE(T�/a�jI ^_1 481 PHONE � <br /> CERTIFIER'S NAME(print), °62 CE IER'S TITLE. <br /> i CL A6414 <br /> NA-VE OF CERTIFIER'S EMPLOYER(DBA) 4" CERTIFIER'S RELATION S '.IP TO TANK cea. <br /> r ❑ I.TANK OWNER [32.TANK OPERATOR <br /> a C"11 G�11!(�tC �NTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5-OTHER AUTHORI;:F I AGENT OF TANK OWNER <br /> UPCF UST-C-12 Rev.(122007) <br />