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Mar 13 09 12:29p Elite Contractors Inc 2094612 p•1 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION I MODIFICATION <br />(One form.per project), <br />Y. F'ACILITXLITF'ORMA1ION:.:: <br />FACILITY ID 9 (Aganty U.ra OWI/1) <br />I'' <br />BUSINESS NAME (Surra as "aftryName or DHA UaingBu~.0 Ar) )' <br />BUSINESS SITE ADDRESS 103. <br />CITY Ins. <br />- ,..... II: ;TN.ST TION / MODIFYCATION PROJEC AESCRIP'I'IOl�fr.. <br />TYPE OF PROIRCT (C*eCk all tial unnfv) ` <br />WORK AU T17I 17.BD UNDER PERMIT °J°' <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2 PIPING INSTALLATION Olt REPLACE dEW <br />• /- <br />❑ 3. SUMP INSTALLATION OR RE)`LACEMENT <br />❑ 4• UNDER DISI'ENSUR CONTAINMENT INSTALLATION OR REPLACEMENT <br />.//� <br />S• OTHER <br />DESCRIPTION UP WORK BRING CLRTIFIED: °61G <br />.. .:r: ............ . .,,., .�,.. . ... ... ... ...,.....-M . T.IO.N. .. ... ..., .. ... ,. <br />7"'' <br />NAME OF COWjRALTOR WHO 1'1.IU'ORMED INSTALLATION / MODIFICA'rION IA4a <br />�Lr�. C7`r1 c <br />CONTRALTOR LICENSE # �dZs <br />LPLD6�lo <br />ICC CERTIFICATION p ` <br />`.�'-:t> uT <br />' • -. IV:`; CERZTFICATI'O.N <br />_ <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met me requirements set forth in 23 CCA §2715, subdivisions (g) and (h). <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 checklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />b a re 'stercd professional engineer having education and experience with undergroundst0ro&C tank Stan installations. <br />SIG NA 'RE OPT TC OW NI CH OR OWNER'S AGENT <br />UATL' <br />CERTIIER'S AML(print) .., ... <br />CERTIFIER'STITLE: <br />NAME.OFCF.RTII7PRBEMPLOYFRSDB�A) ` 'tl°' <br />Cr$��'t C• \ � <br />CERTE'IER'SRELATIONSHE'TOT'ANKOWNER <br />[J 1. TANK OWNL ❑ 2. TANK OPEIL4TOR <br />�. CONTRACTOR ❑ 4, PROPERTY OWNLR <br />❑ 5. OTHER At ITHORILED AGENT OF TANK OWNER <br />I1PCF' USTC Rev. (1X017) • 1/2 <br />Nwrr.u•id• rg <br />