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Mar 13 09 12:29p <br />Elite* Contractors Inc 20946 142 <br />p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />h. FACILITY 1NFORMr1TION' ' <br />FACILITY iD b (ALmmcy Um Oalyl <br />n. <br />BUSINESS AAME (.Y,me A' I.G4ry IVOMW iDA4 BVIi"OSS /iT) <br />BUSINESS SITE ADDRESS Im. CITY <br />ay 3a3 -XoC4 o -w a` C 0. <br />I1H57'ALLATi N7 MUI 1FICA1'ION PRO CT DESCWPTTUN' . <br />TYPE OF PR016Cr (Cheek old th•t Wpb, '' WORK AUTHORIZED VNAER PERMIT aloe. <br />❑ L. TANK INSTALLATION OR REPLACEMENT (NumbWor Dale); <br />2. PIPING INSTALLATION OR REPLACEMENT <br />[1��� <br />El 3. SUMP rNSTAL1XrION OR RE1•6ACEMLNT r <br />❑ 4. TINDER DISPENSER CONTAINMENT INSTALt.A'1"JON OIt REPLACEMLKr 4 <br />❑ 5.OTHLIt._,_ �..,._..J.._ _,.. rx:m. <br />— <br />DE$CVPTION OF W OKK BLIINNG_CERTEIED``: <br />n o t,`QA�t <br />UL CONTRACTOR INTORI�TATION <br />NANBi OI' CONTRACTOR WHO PERFORMED INSTALLATION I MOATFICAI'ION °M" <br />C - <br />CONTRACTOR LICENSE # tP1'' <br />Li b Q LII <br />LCC Clil TWICATION A <br />'7 0 -4 L) . <br />:.. .......:......... IV CE <br />f certify that the information provided herein is trop, accurate, and that the following coaditions 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 installation checklist has been completed. <br />• The installarion has been inspected and approved by the local ag=cy, or if required by the local agency, inspected and certified <br />by a rc 'stored PERfessional ca ' car having education and ex, rience with undertroundmoMSe took systcun installations. <br />SIONWNLK OR OWNLEVS AGENT <br />AATR +r+ <br />PHONE exv. <br />CERTIFIER -S NAM pain) °Yv . <br />CERTIFI,E/R'STITLE: <br />f <br />1 ( <br />1X1. i <br />' NAME OF CERTiFIRR'S EM!'LOY ' A) °NY' <br />CERTEFR R'S RIiLA'f1ONSHIP TO TANK OWNER `W' <br />•. 5 <br />( �)��.v . �, f.`� <br />❑ 1. TANK OWNER ❑ 2. TANK'OPERATOR <br />9. CONTRACTOR ❑ 4, PROPERTY OWNER <br />❑ 5.07HER AUTHORIZED ACENT OI� Y'ANK OWNER <br />UPCF 41ST -C Rev. (1L2ar7) . Iri <br />v,.�.•nidmxrg <br />