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Dec 30 08 10. 26a Elite Iv Contractors Inc 2094616342 p• 2 <br /> UNIFIED PRO+`RANI CONSOLIDATED FORM <br /> UNDERGROUND S'l'ORAc.E TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. ,FACILITY.INF <br /> OI2MATI4 <br /> FACfLITY UD#(Al;wey Vsr Unh'J <br /> 13USINl:SS NA I.(,SamF 9A Facility Jdan brIMA -Uoi'Hg 3avrn .r A.uJ r }' <br /> n ; / BFC 312048 <br /> l3ustN _' S(T, fy1ZLiS5 �- loa. <br /> CITY �• <br /> cOUA1TY <br /> II. INSTALLATIONIII QDIk'iCA,TI4N:_PI O.I)✓C'I'.1? S ,�1�TM€W <br /> TYPE OF PIZi,7dliC'I fCJu kali hnr , l$ — °KS° WORK RUTHORIZLD UNDER PERMIT <br /> ❑ ).-TANK INSTALLATION OR RP-PLACEMT•.N'9' (Number or D.nc): <br /> ❑ 2-NPING INSTALLATION()K RtiPLACEMENT 1 � h <br /> ❑ 3.siIMP rNS'rALLATION OIL Rl PLACEMENT J� ply <br /> 0 4.UNDER VISPENSP-R CONTAINMENT INSTALLATION OR RHPL,ACP.Mr� LL,-�� `f <br /> 5.OTriiiR <br /> Dt-.;U;C ']JON OF WOKK BEING CLRTIFIFD; <br /> pla <br /> M -; <br /> � A'�(ll,?(r ••r Ali <br /> III: QNTRACTf)R 'O'RNIATION <br /> NAML ON' 1'Ult WI;It, U 'D INSTALL AT ON I MUDINICATJON 4Q, <br /> C NTIrAC TOR LICEN5l;# )� €:n. ICC CERTIPICATIO,N <br /> MCAT <br /> . C1NRT', IQN: ,.. <br /> T certify that the information providcd herein is true,accurate,and that this following conditions have been satisfied- <br /> • The instailef has met the requircmcues set forth in 23 CCR§2715,subdivisions(g)and(b). <br /> • The underground storage tank, any primary piping;, and any secondary containment 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 cheeklist has been Completed. <br /> • The installation has been inspected arld approved by the local agerlCy,or if required by rhe local agency, inspected and certified <br /> bv a re •stercd nrofessional engineer having education and ex rience with underground storage tante system installations, <br /> sIONATU F T&UELOWNER OR OWNER'S AGENT DATI: 4K4. PHONL 467- <br /> Joh-S -0 <br /> IZWxNAME(pri °Bf' CERTTTT ER— 7TTLr:: aaQ. <br /> NAME OI'CLRTIFTER'S rM!'LOYER(DBA) '"a CCRTIMER•S RLLATIi)NSHIP TOTANK OWNER <br /> ❑ T-JANK OWNER ❑ 2.TANK OPERATOR <br /> ((10 3-CONTRACTOR ❑ A.PROVJ R'I'Y'OWNER <br /> r S.OTHER Al1THO1(1LLU AGENT OI'+'TANK C1WNI;IC <br /> UPCF UST-C itrv,(1ZJ2Gn-irz .,.�w,uaidescse�r� <br />