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Nov 09 09 10:01a Elite IV Contactors 12094616342 <br />UNTFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUA'D STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />...(One, foan.per project) .. _ <br />as Facdfry Name —WD—B-4 — DnTng B�m�, .4r) <br />I(A E, -C�kRfxc Z vq1 . <br />TYPE OF PROJECT, (Chwk aJ1 that aDnTvl _ — <br />I.'TANK INSTALLATION OR REPLACEMrT <br />0P 2- PIPING A'STALLATION OR REPLACEMENT <br />3. SUMP INSTALLATION OR REPL (MMENT <br />❑ 4. UNDER DISPEA'SER CONTARejENT INSTALLATION OR REPLACEIvIElVT <br />5. OTRER <br />:J)T()MTCn tCta . 9 <br />p.3 <br />WORK AUTHORIZED UNDER PERIvC <br />(Number or Date): <br />5 :hk_ abbc2E <br />ns{ <br />483a On �1�es kO12-1-� to �;mss q <br />(L -c- � teS� u f� -3CGO- afuk Ptp( on +)\c SZ un1codeel.. �'� CLOG <br />&n t�A- W21-09 P � URJ i a,Ftr frc-Vcx r .oF <br />kC c _o-rj� " ALL, PQ5�1. <br />l '1 <br />(-0 bX 0 W\ <br />CONMZACIOR LICENSE # <br />CScUc W�� <br />V <br />I certify that the 'information provided herein is tme, acenra <br />te, 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 <br />voluntary consensus standards and any manufacturer's written installationistmc to ment was installed according to applicable <br />All work listed in the manufacturer's installation checklist has been completed <br />The installation has been inspected and approved by the local agency, <br />b a iseor if required by the local agency, inspected and certified <br />stored rofessional engineer havingeducation and erience with and ound storage tank stem installations. <br />-AwJ : ,URE OF TANK OWNER OR OWNER'S AGENT <br />/111. /)I DATE 494. PRONE en, <br />I..CMZTIFIER'S NA?A (print) <br />NAGM�E OF CERTIFIERS EMPLOYER (DBA) <br />qLE <br />Z>M (LhL <br />UPCF UST -C Rev. (12/2oom -112 <br />. ;07TM-R <br />3M.E: tiST dK5 �Lk�tk n <br />ag -Trr O <br />CERELATIONSHIP TO TANK OWNER <br />WNER. [J Z. TANK -OPERATOR <br />�ACTOR ❑ 4. PROPERTY OWNER <br />❑ AirrUnVT7=n .���., �.:.. <br />www.unidomare <br />