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Sep 29 09 10:52a Elite IV Contactors 12094616342 p.3 <br />FACILITY IJP # (Agency <br />BuMPSSNAtvMrwme <br />BUS S SITE R1 <br />.4 <br />•b' M)). PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />y Name or DBA - Doing Busimm AS) <br />7103-CUFTY77_�� <br />e;:. ,a ;.rte . 1. , . , _--_--_1--_ . <br />TYPE OF PROJECT (Check all that aaal vJ <br />40&WORKAiITHORIZED UNDER PERMIT <br />Q I. TANK Q ISTALLATION OR REPLAGEh(ENT (Number or Date): <br />Ej 2- 'PIPING INSTALLATION OR REPLACffivllrN S�- -'I <br />Q: 3. SUMP INSTALLATION OR REPLACIIvl Wr <br />r'I. a- rnmm DISPENSER CONTAII&eNT INSTALLATION OR REPLACEMENT <br />NF`� CT� dP� IAT,�\iONJMODIFiGAT10ly <br />CONTRA, OR LICENS ICC CERTIFICATION # <br />3. <br />Ru <br />a*n <br />I certify that the information.provided herein.is true, accurate, and that thefollovvins conditions..have been satisfied: <br />The ineAer 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 containment. was installed according to applicable <br />vdiuntary consensus standar&4nd anymanufacturer's written_ -installation nslrndions: <br />- ill "Work listed in the manufacturer's -installation cheddist has been completed <br />he local agency, inspected and certified <br />The installation. has been inspected and approved by the local agency, or -if required by :_t <br />b a re ' mfessional en ' eer Navin education and erience with un and Stora a tank stem installations. <br />SIGNATURE OF TANK OWNER -OR OWNER'S AGENT DATE 4� PHONE <br />;a• vPCF UST C Rev. ( .00h -112 www.onidecsArg <br />