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Feb 02 10 10: 04a E1ite,,f Contactors 120946342 p• 2 <br /> U 'I '0T ')PROGRAM CONSOLIDATED FOR11j <br /> U11'DERGROUIN'D STORAGE TANK <br /> CER"IFICATIQN OF INSTALLATION/MODMCA TION <br /> FACII.,II'y tD;,(RSene3'Use On1If �. k���r�� .�;� O � �< �..`r-x �•�'�.�"`R'�t #�r7 �r ,x�.�., <br /> BUSINESS N w* <br /> _ �}''�MEf5ame ar Fnriliry lbitmc or IaBr!-� S <br /> }(,�1 <br /> 1 �OIn BUNT- �•) <br /> SS <br /> l <br /> BUSINESS nB ' s' <br /> AnnR�ss <br /> crry <br /> Lr4.1is <br /> �����c� <br /> TIFIECT�Chce <br /> E OF PRO k ' 21 ±CSE M <br /> adl thin annit• R.,.T.. _ .v 3 _ ' s <br /> .,qr... •r�.+ t <br /> 1�.I.rANlL INsrAGI 4TION OR REPT ACES ' WOR.K AUTHORIZED UND> R T .ERIC . fi #ar, <br /> ❑.?PIPING STALLATTON OR RFPLACEh4ENT (Num2a:r or Darr): 4an <br /> C] 3.SUhIP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTA111v�*t INSTA Li ATIDN OR REPLACEAINT l 1 <br /> S.OTHER <br /> CRIPTION OF 1A OF.K BEING CERTIFIED: <br /> }gel fc� t��u p tjI"II- - �uC { <br /> NAMEt)PCONTR4CiORu$IOP� T , a ; ~L7L'C� <br /> ERFDRMEp fA'STALLATION/MODII TC,eiTION � r. w x 5 � "` <br /> '.0 <br /> X;Ffy m <br /> CONIRALTOR I ICENSE# JJ ' <br /> l�J <s2s ICC CERTMCATIOY# <br /> It-/1 5�1 <br /> u" ." .1S L.ilq,-„•>_1G •R"�s .+ R ..r � �' F� M� Y�'fi:P'arK 9 !•�.�i{"iF6� � �y <br /> - .. . .. .. ,.+o .,, -"- _a..mreaer.na,v mot+���.L:. "�k ' �I"^" ai•,1"'lia:•e rl a"'.a t•.-wtia,.�.q <br /> P herein is trrl acc ���� � <br /> e, errata,and that the f6llu` 'ing cond'trous have been satisfied: <br /> • The iustallerhas met tlxe re <br /> 4uinements set forth in 23 CCR§2715,subdiv sions{g)and <br /> • The underground storage @)• <br /> e any p�ary Piping, and any secondary containment was in <br /> vohmtary consensus standards and any manufaeturcr's stalled according to applicable <br /> • All work fisted in the manufactu written installation instructions. <br /> 71e installation has been ' mr's installation checklist has been completed. <br /> a b a registered rufessional ended and approved by the local <br /> est having education and ea a with and d sttora tib IIester acted and certified <br /> SIGNiyTURE OF TANK Otiy��OR Q11 <br /> r 'NEB's AGENT DATE installations, <br /> aea.. PHON487. <br /> E <br /> ra � <br /> ��. I'C a3�1 <br /> CERTIFIER°s ...NVT vif `�Z 48C, <br /> NAME OF CERT7FIEtt S>�LID (DBA1• a6&. �'JC `- �L l°L <br /> L`}' j� <br /> l lc 4 Y �1 r " �+ �1°11 R'S RELATIONSHIP TO TANK OWNER ass. <br /> T i�� �(' -f] I-TAN OWNER El'iTANKY?PERATOR <br /> 3.CONTItACI OR © 4.PROPERTY OWNER <br /> OTHER AUTHORIZED AGENrl OF TANK OWER <br /> UPCF UST-C Rev.(I2120”_IR <br /> '+w'3r.uWdocLarg <br />