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Feb 18 10 10: 53a Elite TV Contactors 12094616342 P• 1 <br /> UNDERGROUND STORAGE TANK FORM FEB 1 8 s' <br /> CERTIFICATION OF INSTATJ rATION/MODEMAS'�I,�1�T ��1p <br /> .(One form.PCF 0, c[)-. .. Fti� ,•:,..�,.'. <br /> LA- <br /> FACII,ITY ID#(Agmry UscOnly) - -' <br /> BUSIt.IESS NAME(Smne osFadliNName—or�DB��JlbingBuruar AsJ 1 <br /> TYPE OF PROJECT(Checkcll thm rtvnly) - gym` WORKAUTHOR=)UNDER PERMIT ' <br /> ❑ I:TANK INSTALLATION OR REPLACEMENT (Nambrar Date): <br /> ❑ 7 PIPING INSfALLAnON OR REPLACEMENT <br /> . ,f]3.SUMP INSTALLATION OR REPLACENIENT ..•111 <br /> .0.4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> DFSCRIMON OF WORK BEWG CERTIFIED: <br /> ctJJ . Z i � <br /> �Po , <br /> N OFCONTRACIORWHOPERFORMEDINSTALLATION/MODisc.AmIN Feu <br /> CONTRA ORLJCENS - - �. ICC'CER=CATRINM <br /> iGcx� �f� ga yy.q- <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 2i CCR§2715,subdivisions(p)and:(h) . <br /> _• The underground.storage tank, any Primary P!pug, and any secondary containment:Was installed according to applicable <br /> . ..voluatatyconseas u standards and any rnanufaeturer's=mrine¢'.installation=inM.;,m04s.+ <br /> • All work.listed in the manufacturer's.installation checklist has been completed. `. . .. <br /> The installationhasbeen inspected and.approved by the local agency,or.i£ the local Agency,itnpeoted and oertiSed <br /> 1xY:; <br /> ti a ' fessionalengineer havmeeducatimand 'encewith took installations. <br /> . SIGNATURE OFTANK OWNER OR OWNER'S AGENT DATE - ne< :PHONE <br /> .S, w.- - .as. CERTJEIER:S.TfD.E: - uL <br /> Com. �ervJC � - <br /> NAt�OF CERTIFIER'S EMPLYER(DBA) CFRTIFIER'S RELA27ONSHM TO.TANK OWNER <br /> \ "❑ 1 TAN IFDWNER ❑ 2-TANK:OPERATOR <br /> .OTRERAUM ❑NTOF TANK OWNER . <br /> :J�J .OTHFRA ITIHORIZED AGENTOF7ANK OWNER <br /> DPCF1USI-C Rev.(1 a97)-1/2 www.vnidnsorg <br />