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Feb 27 12 09: 27a ElitIV Contactors 120946342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FO 'H <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/hl DDMCAnCg8'2 7 ?0 r <br /> (One form,perproject) <br /> y _ <br /> •.':+`. '�zl '�-k ° w"°"'."'+'v. <br /> WE <br /> K✓ <br /> FACII,I'I'Y W 9(Agency Ure Only) <br /> BUSINESS XAIdE(Bama as Facility Name or DBA-Doing, BusiacstAs) <br /> Busmi Ss SITE AUD" Im. CITY — - <br /> y 1: luLav I+L:•i <br /> uuy IrY <br /> .i. <br /> TYPE OF PROJECT(Check all thce aoa/v)� 4� WORT:, _THORIZED TINDER PERMIT 493b.. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Num x )rD=):. <br /> .0 2.PIPING INSTALLAMON-ORREPLACEMENT <br /> 0,3.SUMP INSTALLATION OR REPLACEMENT <br /> 1] 4..UNDER DISPENSER CONTAW ENTINSTALIATTON OR REPLACEMENT . Y IY ,! „ <br /> DESCRIPTION <br /> OF WORK BEING CERTDUD: <br /> I . <br /> c!ficv, <br /> 1140V <br /> 1"51g._U LS <br /> 70 <br /> NAME OF CONTRAC'OR WHO PERFORMED INSTALLATION!MODIFICATION 4� <br /> l il'1fi2 .C'.'f7; <br /> _ CONTRACTOR LICENSE#/, ! {I I� RTIFICAT1ON# 4&1` <br /> n' y26 ,wl tYl. 4�{qp���� M' KTi+tiN1:!k1Y� tiRYa .!- Pi ��A 'C.,.T. •T� •` <br /> I certify that the information provided herein is true,accurate,,and that the following 4 o: cations have been satisfied: <br /> e- . The installer met the requirements set forth in 23 CCR 62715,subdivisions(g)and ili <br /> • The underground storage tank, any perry piping, and any secondary coutainmeld eras installed according to applicable <br /> _ vohmtacy consensus standards and any manufactures written installation instructions. <br /> .. .. <br /> .. Allwork listed in the:manufac(uter's installation ctlecldist bas been.completed ' . .: . . <br /> The Installation has been inspected and approved by the local agency,or if required by f :local agency,inspected and certified <br /> a ie •stered. rofe'ssional ert ' eer having education and experience with undergimik s )rage tankSystem'installations. <br /> SIGNATURE gF TANK OWN OR OWNER'S AGENT "' DA• Ff PHOT _ 4n• <br /> CERT °m' ..CER 'S.TTTLE. <br /> P. <br /> N OF CERTTFIEI,CSEb2PI:0YER(DBA) :4a' CERTIFffit'5.REgATTONSFI& �3TANK`OWDIER . en. .. <br /> y / .r',((',/ "Q 1 TA-NKOWNER j'22A-NX-OPERATOR _ ... <br /> V JJ n �/ 1. pF7/ /�GONTRA.CI,pA j 4.PROPERTY OWNER <br /> 0. �V�[CC.YpKS.'OTHERAUTHORLZEUA 73i'I'OF TANK OWNER. <br /> UtCI+UST-CRev.(1ZlWOI)�1f2 ww•w.imidorsorK <br /> : <br />