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Oct 03 13 08: 14a Elite IV Contactors 12094PIS342 p. l <br /> RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED!?( SRM - <br /> . <br /> UNDERGROUND STORAGE TAM-: OCT 0.3'2013 <br /> CERTMCATION OF INSTALLATION/Al 011MCAT��v <br /> cQir .ec*- �N,VIRONMENT L <br /> FACMnY MitUp m7 Me On771 <br /> - <br /> [B7U91N=NA&M ='ftWayJV men DBA—DjZZBadwAS)Ll <br /> STfE ADDRESS w N im _ q. <br /> c. <br /> v �a <br /> '. �❑❑0 1.TANK <br /> AID TALLA6'n(TtlRARIIE.EPvrffi)-P.I._ N WORK UI�HORM" <br /> W UNDER PERMT <br /> ❑ 2 PIPINGINT [IATIONOR REPLACEMENT (Nmub xDne): <br /> 3.SUMPINSFAATtONSRREP.LACEMENT <br /> 4IINDERDISPHNSFBCON1NSTALLA70EN674,)7q <br /> - <br /> 5.OTIM <br /> DESCRIPTION OF WOR K-BEAIOCERTB�lED• — �e <br /> d m4iiil 41 r x G� r <br /> bd) i�114e.r C1j1 (%f25�i �: <br /> WHIM w <br /> NAME OF CONTRACTOR WHQ'P RnIED S TIDN/MIO IFICA710N em. <br /> A' <br /> CONTRACTOR SEA ' <br /> S" L,�JCv ICcCEFfUT��;% J . .:. . .� <br /> k• .W TNN in , <br /> J <br /> I ceritfy that the fWformatioa_provided herein is true,accurate,aad that thefofloWIng,:o sfled: " <br /> - The installer has met the requirements set forth in 23 CCR§2715,sabdivisions(g)aad.'fi <br /> • The nndetgrotmd storage tank, any.primary Pip�B. and any secondarq wntat�urt g to applicable <br /> _ voluntary^censeosus-standardsandany.mmmufacttrier'swrinm-iWhdIationjnShuctiom_s,- .. - . <br /> • All'cvork listed in the maaafacturer's ins tall ation ebe,*Iia has bean comp]et0 . ..... - .. . <br /> • <br /> The instsilation.luiv been inspected:and approved by the local-agency,or if required b1-.1 ad and certified <br /> b s 'stercd fessional� • ear bo ' cdtuationand •ence Witk un 'rma(� rlatidns. - <br /> SICNATURE TANKO AR OWNER'S AGENT DATE _ -4-7 an <br /> N C tCER <br /> i-,"E 'SEMPLOYER(DBA) : °B8 �rca•rrxrcc•S.RELATIONSFIip OrANKVWNER •sc. <br /> , ❑ 1 7'JQ OWNER ]2.TAMC'OPERATOR <br /> rn�eC70R ] 4 PROPERTY OWNER <br /> � /� ✓ ❑ 5.OTHER AUTIIOR.IZFI:A !ENTOFTANK OWNED: <br /> UPCF UST-C Rev.0=007)' 22 - www.unidoes.oxp <br />