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Mar 13 09 12:25p <br />Elite Contractors Inc 208461 06342 <br />p.3 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />L. FACILITY IPT.FORNIATION. <br />FACILITY 10 N (ASeKv U.m (lah) L <br />BUSINESS NA -(Jane ar r..wr Nam or DBA -/Acing Bwia A.r) <br />BUSINESS SITE. ADDRBSS Iw. <br />aL4 3a3 q <br />CITY 104. <br />c o <br />_,�cx wt <br />IL „NSTAaATT N) MOI AFICAT.ION PI20i&T. UESCRIPTIUN _ <br />TYPL' OF PRMrCP(Chae.k &Llyjr,qjMjjv °R't'' <br />WOW: AUnOKIZED UNDER PP.RMIT 4tw. <br />❑ ). TANK INSTALLATION OR REl-LACL'MENT <br />(Numher w Dam); <br />❑ 2.)11)'ING INSTALLATION OR RITLACEMENT <br />Q 3. SUMP INSTALLATION OR REPLAMME'NI' <br />❑ 4. UNDER DISFUNSM COh tAINMEN'f INSTALLATION OR RFPLACMAENT <br />. Q 5. OTHER <br />DESCRrr'nQN'OF BLINU CERTWIFD: 40.. <br />WORK <br />C -A- '4-V\+C_ f`t10 Yl�'�"..L6-1 n <br />o-� rn (`c�Tr t <br />(low <br />Q_r <br />TIt. CON1`RACTUR INFORMA'T'ION <br />NAME OF CONTRACTOR WHO PEI(J,U1kMED INSTALLATION / MODIFICATION °D• <br />CONTRACTOR LICENSE 4 4111 <br />ICC CERTIFICATION R <br />`. ' N , C,E12T1FfCATTON` <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has mct the requircmcats set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The undergrowld storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instnlctions. <br />• All work listed in the mar ufacturer's installation checklist has been completed, <br />• the installation hub been inspected and approved by the local agency, or if required by the local agency, inspected and ccrtifed <br />by i registered Profebsion2l engineer having education and ex. 'encc with underground sturagc t nk system installations. <br />N E OF TANK UR OR OWNER'S AGENT <br />DATE °"' <br />PHONt °"1. <br />�'SN npn °%' <br />E <br />CEFrTIFIFR'ST)TLL- °X6' <br />' NAME OF CERTIFI;E-R'S-EMPLO $N °MX' <br />CERTIFrFR'S IU.LAMONSHIP TO TANK OWNliR °A1 <br />�� ( •l,V-• C(j`(', ��� �`j <br />❑ 1.7'ANK OWNER ❑ 2. TANK OPERATOR <br />3. CONTRACTOR ❑ 4. moPFRTY OWNER <br />❑ 5. QTHUR AUTHORIZM AGBNI' OF TANK OWNER <br />UPCF ITSTC Rav, (1'.2807)' 12 <br />w%rl-'nidcmorL' <br />