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Nov 06 09 11:59a Elite IV Contactors 12094616342 p.2 <br />UNrWMD PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />...(One, form.pes project)_ _. . <br />(Agency Use <br />(Same asF--XI Name—DBA—Doing <br />'10f E�-C4RUCP w . <br />TI'PE OF PROJECT (Chestafl tharaenh d , a <br />0 I. TAMC INSTALLATION OR REPLACEMENT <br />_N2 LL <br />PIPING INSTALLATION OR REPLACEME-WT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTA 4N E Pr INSTALLATION OR REPLACEMENTrl 5_ oTTTFu <br />OF <br />3,10MRn (CR . Qi <br />WORK AUTHORIZED UNDER PER -MIT <br />(NumbeGber or Date); <br />v�� <br />K� �� /n l I <br />�ISQeC,�oC (,5 Gt1 -04-�J- to 12i 7cig to CQ, <br />(J� +1`2> -3er�ei� � <br />�P +p crq ort 4\o 8Z <br />6rlwec te,6 W 2-0'-� p red vUe1 i c� � fY�� re-�c;�r of <br />rrr_fcx-� ccM(xesIC11-1 tkID3 + C�te� 1 <br />u <br />.CONTRACTOR LICENSE # <br />ICC CERTIFICATION �^# _ �/ y /L 40x <br />I certify that the information provided herein is true,.accarate, and that the following conditions have been satisfied: <br />• The installerhas met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground. storage tanlS any primary piping, and any secondary containment was installed according to applicable <br />vOIuntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's •installation checHist has been completed <br />• The installation has been inspected and approved by the local agency, or if required by the Iocal agency, inspected and certified <br />b a m' 'stored igofessional enggizeerhavjng education and expenence with unde unel storage tanksystem installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4s4. <br />487. <br />CERTIFIER'S NA?& (print) <br />NAME OF CERTIFIER'S EMPLOYER (DBA) <br />CtQCM 2 6_h : <br />35 . <br />UPCF UST -C Rev. (IZ7007) -12 <br />TS.RTIF�R'S TTT1.FTIFIER:S RELATIONSHIP TO TANK OWNER <br />L T^TK'OWNER2 TalN7C OPER TOR <br />CONTRACTOR [] 4. PROPERTY OWNER <br />.OTHERAUTHORI7.Fn Ar:Frrrn;-re**v rnn r. <br />www.unidocs.org <br />