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Jun 18 10 12:16p Elite TV Contactors 12094616342 p.1 <br />UNIFIED PROGRAM COI�TSOLIDATED FORM <br />UMERGROUND STOPUGE TANK' <br />CERTIFICATION OF INSTALLATION / MOPM. CATION <br />. .: :: (Orie ,fonn.per project).:... --�• ' . ' <br />!'.t," �s (T1I7� —77-4 <br />w' .fir x- <br />:. $U NAME arFatiliryNamc or B,�i—DairegBvsia.:ss drJ •3• <br />BUSINESMMADDRESS. !03 :E 1(1nONPPt=N tot <br />'RTMENTtaw <br />TYPE OF PROJECT (Check all that aanivl. ` WORKAUTHORIZED UNDER PERhM' �a3d <br />]] I. TANK INSfALLATTON OR REPLACFJvIFJ�1T:.. (Nambcr or Date): <br />]D*." PIPINGINSTALL4TTON•ORTEPLACENJENT <br />" SU2AP INSTALLATION OR REPL .CENT <br />4: UNDER DISPENSIIt'COhTAII�➢blEt�! SNSTALLAI ION OR REPL 4CE1\�N f <br />5; 077-IER <br />_--DESCRTP�lON OF3iu • ERJG• ---- ----— <br />S <br />ao <br />'A <br />1� on <br />V. <br />4,, Q T l-1 0 k 0i i=. _4t'., 1111at f <br />N F Q CTOR P O INSTALLATION IMODIFICATION_ <br />]\ CJ'ORLICENSE# ICC'CERIMCA ON'# 4924 <br />7--Th�-' <br />��.._�a"7� h -rg,e?�s.tr.z�r:that the information provided herein iis.trne .accurate, and that the followin coudiiions have been satisfied: <br />-iastaIIerbumet-the regize encs set Earthin-33 CCR, 2715,':sabdivisiops (g)underorouud storage tank any Pmma?ypiP�S, and.anry..secondary cantainment;�vas Installed -according .to applicable <br />niy' consensus standards -and any manufacturer's writteniastaUation-instnic ions;.: ori: listed.in the acturcr's •installation nstaIiation has.l en inspected and approved;irythelocal aD�eacy, or ifrequi ed by the Iroietrrrri nrrafnecirmal [�noineYr Ftavinc &dnnatinn and eime ience with underErallndstora—ve faIll:'S$'Stenl IDStflllat]ODS. <br />