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Dec 1.6 09 08: 20a Elite IV Contactors 12054616342 p• 2 <br /> UWff ED PROGRAM CONSOLEDATED FORM <br /> UNIDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION f MODIFICATION <br /> (C)oe,form.perprojecz).. . _. <br /> y .�".f'°" <br /> ��}a,� __ ,,�.� -.a,„C`,Y" �i�..1�_ � .u.wnu.r..wog• ra..�aM ��s .i' 4-� �i <br /> FACILtI'1'ID#(Agency Use Only) <br /> 3. <br /> SUSINES,S NAME(Same ar Faeiliry Name or 175.9—L)ning BusinessALrJ <br /> BUSINES SITE ADDRESS ]03. CITY 104. <br /> rTq . <br /> L'flc,F.Y ,. ,�.`.:'1 .:—.„'�'V....i .r - ._;c• r._tea.,, a.. .wa=•r�.,.wx:.r.-r, w.wo ,m+. e. n^,F.+ <br /> TYYE OF PROSECP(Check all thmanyli "Wa WORK AUTHOR=UNDER PERMEC 493L© .1.TANK INSTALLATION OR REPLAC 'T (Number or Datn): <br /> © Y.PIPING INSTALLATION OR REPLACEIVfEN T <br /> Q 3.SUMP INSTALLATION OR REPLACEa NT <br /> Q 4:UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCP.3PTlON OF WORK 13MNG CERTIFIED: 493c <br /> I�IIcpIom OPW - I U 2.kc0c. <br /> ESA 0 �'3R CXCN mon'ln RP 1 OU W P;�) PP'bt.I l2--B fv` fhc <br /> _ - xr�v _•- } -tea.-�..,..eu.v -'•• g_ <br /> .zti,�, ....e.-. .,,srr.a. xru.-.;s..ave- _ <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALIA-M)N I MOD1FTCATION 492.L <br /> r <br /> CONTRACTOR LICENSE# asw, ICC CERTIFICATION-# aha <br /> �asl <br /> `aL `..T.I,.:iJ it•`e M.�M+r.k ..1.'Rc. .yy <br /> I certify that the information provided herein is trite,accurate,and that the Following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR.§2715,subdi visions and <br /> • The underground storage to �►) <br /> voluntary consensus �' any .Primary piping, and any secondary cantainmeat•was installed according to applicable <br /> y Standards and any manuf'acturer's writt=installation instructions. <br /> ■ All work listed in the manufacturer's installation checklist has been completed_ <br /> • The i=Wlatioin has been inspected and approved by the local agency,or if required by the local agency, inspected and c-riified <br /> b a E f:TA d professional entdne�er hayin education and ea enence with-under tmd storage tank stem installations. <br /> SIGNATURE of DANK OWNPZ OR OWNER'S AGENT <br /> I DATE eat. PHONE <br /> CFRTTFIDt'S NAME;0,j6t) ass. <br /> CERTnM R.'S.T=: __ 486. <br /> NAME OF CERTIFIER'S EMIPLOYER{DEA) ass ZW . <br /> EMS Ta co,A �y, CErtTTF�R'.S RELATrorrsHIP To Arlx awNER 439. <br /> TANK OWNER fl 2.T.4AlR OPERATOR <br /> cONTRACI'01[ <br /> ❑ 4.PROPERTY OiA NER <br /> ❑ S.OTHER AUTEIORIZED AGs"M OF TANK OWNER <br /> UPCF UST-C Iiev.(JW-00't) Ili <br /> wwr;tmidnesore <br />