Laserfiche WebLink
Nov 26 12 11 : 36a Elit-IV Contactors 120946 42 P. 1 5Vj <br /> UNIFIED PROGRAM CONSOLIDATED FOW <br /> UNDERGROUND STORAGE TANK nn <br /> CERTIFICATION OF INSTALLATION/MO 1sIFICI� f 012 <br /> MALI rte f rm per project) <br /> e <br /> L FACILrIT INFORNIATION ENVIRONMENTAL <br /> F <br /> FACMiIY ID (Agency Use Orly) -- '' -----�I---'���,JlF AHR H <br /> BUSINESS NAME(sem:recauv nnn¢ornaA-o,;,,s s,�;nm n.) y <br /> fRIN <br /> BUSIIN/ES/SITE ADDRESS — <br /> I�I.P <br /> . ? IL1.VSTAI:. ATION/1�40DIFICATI,ON 1"ROJECq,']SE:i Z i�T10N., <br /> :. _ _ _ - <br /> TYPE OF PROJECT(Check ell that eooly) d8i" WORK A U 410R12ED UNDER PERY[IT sm. <br /> ❑ <br /> I.TANK INSTALLATION OR REPLACEN¢tr"f (Number <br /> ❑ 2.PIPING INSTALLATION OR REPLACEIv¢p"T <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER 1vA��� ��[[�'t <br /> DESCRIPTION OF WORK BEING CERTIFIED: IU U IV V ( ��LG, ♦,1UJZ•t• /p�,I�' Uty / W.Y/; <br /> • I <br /> �11uh z � 1ti �� ct Eu�,m) � la i, ru�rt <br /> R '51 P w %ti- 6-i- i ac a•Vn n'� , u�l cJ� <br /> � <br /> -7111 I r z tit/e �e ; �Chau�kms, <br /> Ord PIVPl lamlY <br /> all ' <br /> coay. lcTo 1 (IRnaa rtinr <br /> N 0O O INSTALL N/ OD(FICATI <br /> CO 4CIORT-CENNSEf ICCCErXCA� <br /> 1N.C9ERTMCATIO/T/>iN " 'UY` <br /> I certify that the information provided herein is true,accurate,and that the following co.tt tions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h.I. <br /> The underground storage tank, any primary piping, and any secondary containment v is installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> The installation has been inspected and approved by the local agency,or if required by t it local agency, inspected and certified <br /> re istered professional engineer having education and experience with underground SIC 8oe tanks stem installations. <br /> 1GNATURE 0 NKO^"/ 'S AGENT <br /> t \ DA'? /f z — P(Zoq AJ..I <br /> CERTIFIER NAME(print) _ ,81 CERTIF (S TITLE: _ 7LY nb. <br /> FC <br /> EMPLOYER(DBA) 188 CERTIFIER'S RR ATIONSHB'7 TANK 0 189 <br /> r I ❑ L TANK OWNER E I TANK OPERATOR <br /> 3.CONTRACTOR F- i PROPERTY OWNER <br /> LLL S.OTHER AUTHORIZED,G NTI OF TANK OWNER <br /> UPCF UST-C-1/2 ry � <br /> Rev.(122007). <br />