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Jul 08 14 07: 46a Elite IV Contactors 12094616342 P. 2 <br /> UNIFIED PROGRAM CONSOIA'IET P RF <br /> . . ,UNDERGROUND STORAGE TAN i R <br /> CERTIFICATION OF INSTALLATION/P ODIFICATPON <br /> o-e u , - Y ?r-.,-•(On�e form.Pu'P?r_leQtZ_ _: 9g - y[ - JULL�' 08 2014 <br /> . <br /> FA �s(ea�aPVnonbd IT <br /> If1 E., T YQRInJ'..i <br /> ' BUSWPSS NAME(BRwe as FaeiliryNmx orOBd-Doirzg Buriacrr As) �' <br /> e-c�kCi <br /> BUSINESS SITE ADDRESS CRTY <br /> e <br /> TYPE'OF PROJECT(Check.11 that aanlvJ 4 WCIR AUTHORIZED UNDER PERMIT 4tlb. <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT CT'in t r or Date): <br /> ❑ 2 PIPING INSTALLATION OR REPLAMIENT l <br /> -❑ 3.SU20 INSTALLATION OR RCRr'�r OdENr -..i1 <br /> _-. 1.. .. .. . <br /> ;❑ 4.TJNDER DISPENSERt'ONT INSTALLATION OR REPLACEMEri-7. <br /> i.OTHER <br /> DESCRP71ON.OF WORK BEING CERTIFIED: - -_ _ 40L <br /> f61�T � �� Tb lt�t'tEY �iT��]f, sttiutc>r� -� �SenSct' <br /> dF �lfG GJnT U elf ' PSLaC-vCO Pfa`YD NU f <br /> 1�1c7E �t1£ itrU � `�� i�t� � �5 t2c; f�lJ c <br /> St�T.OGIt?fl Se.ilk'{`S . Ct�t�r2tLL�Q_: ll tb7 C:t)nC�iCCi <br /> t ntikr( t pane E '�zrsh t . . <br /> � <br /> Own <br /> `Ve�'kti shic� ac (�'1 _icer . J <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION MODIFICATION °gym <br /> El 11 CtydRtt-t[!fS I if ilt ., <br /> OONTRACTORLICENSE# /�/./'1I"1/n A_0./� I/\ �11�7 4�' ICC CERTIFICATION N <br /> llllUll LVA t�LIIJ lv `r11. 6� c <br /> Ony lv2 e (2 <br /> � <br /> 7.AN <br /> at the infoim6tion provided herein is true,accurate,and-that the folk-whi8 bnditions have been satisfied: <br /> taller bus mei the requirements set forth in 23.CCR§2715,subdivisions(Z)a at (h). <br /> . underground storage tanit;.:any:primary:piping;:and;any-decondlary contain nt. was installed according to applicable <br /> ryconsensus Standalds.6d-any manufectt iI Written installation instructions <br /> k listed in the manufacfiiret's installationchecklist has been completed. <br /> tallation has been inspected and approved by the local agency;or if retpdrv..I i the local agency, inspected and certified <br /> hv a' "stored - -fessional"en"neer hiving'educatioaand experieacI6 with undI 3 straliI tanks stem installations, <br /> SIGNA FT O R WNER'S AGENT DATE p. ' N° PHONE 417. <br /> CERT 'S NATAE(print) .7 4es. CERTIFtER'S TITLE:: t -C-1 <br /> NAME OF CERTIFIER'S EMPL C <br /> OYER(DRA) f 4sa. $ERTVM'S.R1%ATIO J! IIP TO TANK OWNER1,TANK <br /> 2. <br /> ELM- N� 0 ^ f-0 -,`C"� 1.: (f� � �I 3.CONTRACTOOR El 4.4.PROERTY OWNER <br /> n <br /> 5.OTHER AUTHOR Zi .AGENT OF TANK OWNER <br /> -:'- III UST-C Rm(122ae'I)-t2 - w w.unidam.org <br />