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Mar 13 09 12:25p Elite Tv Contractors Inc 2094612 p•2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGX TANK <br />CERTIFICATION OF INSTALLATTON / MODIFICATION <br />(One form per project), <br />...'' .. x.� FACILITY INFORMATIO�i . ' <br />FACILITY ID # (A,,ewy Ow Delv) <br />�. . <br />EUSMUSS NAME(Some Faciliry Nome or DNA- Doily;Hesinesr A.p t• <br />j <br />-�W K'�nT 'G'C. ` FL.".0 \ <br />RUSINLSS SITU ADDRESS 1w. <br />CITY <br />43.E 3 A( } �� �\. �>, ��� <br />A <br />It ]Nst 'LATION / 11�OD1FICATION PROAC , DE3ERII'TI0N ' <br />�TYPE OF PROXCT(Chmk0thureeply) �— asx <br />WORK AUMORILED UNDER PERMN' °K1^ <br />❑ 1. TANK INSTALLATION OR RF.PLACr.MENT <br />(Number or Dau:); <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. sAMP INSTALLATION OR REPLACEMENT <br />1] a. UNDER DISPENSIA CONTARVMLNT TNSTALLATION OR IiEFLACP.MENT <br />JQ S. OTNER <br />DESCRIPTION OF WORKBRINGCIiRT FILD: <br />Y' � inst_�"c' C? �j-T m L� �.�v�I•�'1 �C``J�.�A� ��- '`l� •�i'_� L <br />. t„- . <br />IIL CONTRACTOR .. R INFORMATION <br />NAME OF CONTRACT -OR WHO PERFUKMED INSTALLATION / MODa11CA110N °W^ <br />CON'IRALTOR WCENSE# °X3°' <br />Lvloy-4-lo <br />ICC CIERTIFICATION# ` <br />IV. CERTIFICATION <br />I Certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />The installer has met the requirements set forth in 23 CCR §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 instillation checklist has been completed. <br />The installation has been inspected and approved by the local aCency, or if required by the local agency, inspected and certified <br />by a 'ster Professional tm •infer havingeducation and eK cricnce with un ound Ftoragc: tanks tem installations. <br />SIGNAT P13 OF TANK OWNI:"I[OR OwNL-R'$AtiE.NT <br />DA7't °MPHONE <br />Lf <br />cam' 3 3 <br />•C.CRT1'IF7t'S AME(Priuq - Ws' <br />CERTIFnEWSTTTLL•: <br />/ . <br />.`tee r ' k'\ <br />NAME OF CER.TTIFIIER'S EMPLOYER (yllDA) � <br />CERTIFIER'S RRLATIONSI'RP TO TANK OWNER °N'r <br />❑ 1. TANK OWNER ❑ ..'TANK OPERATOR <br />.CONTRACTOR ❑ 4. PROPERTY OWNER <br />(❑ <br />S. OTHIi1t AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Ite.. (1212007) - M www.anid, ¢ wg <br />