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RuZ 02 12 07:41a Elite IV Contactors 12094616342 p.2 <br />UNIFIMD PROGRAM CONSOLIDATED T( IM <br />UNDERGROUM STORAGE TANK <br />CER171FICATION OF INSTALLATION ! MVMCATION <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME (Same as Facility 1Vame or DB.G -Doing Breriners ASJ - 3 <br />BUSINESS SITE ADDRESS Ina. CITY - 104. <br />. F _..wl` A'4.i `'�' _w*.' tL... L ., __+S.r+T4P!. ��wW. i'i'i dG:-�?i3-ifi 3� �'.7a. - •'i'!M'TLf).� <br />TYPE OF PROJECT (Checkall drat annlvl 463- WOIt .401. <br />:)YRO UNDER <br />❑ . PERMIT <br />I. TANK -INSTALLATION OR REPLACE)V(ENT; (Nor ib • :)r Date): <br />[] '2. -PIPING INSTALLATION OR REPLACEMENT il- .�[ %% ��' I , jj <br />Q, 3. SUM INSTALLATION ORREPLACEMENT �5� 6V�J l�1 ' <br />El. 4. UNDER DISPENSER CONTAINMENT INSTALI.AYYON OR REPLACEiA1 T <br />S: OTH£it <br />-•-=•----.------.,.----•--DESCRIPTION.OF.WORKBEiNG.CERTIFIED:-..----....�...._._._—___..;...__— _-__.._..:.-.------•---...... __+8k.':_�_� <br />-vo wcr.�� �hf.J .b� AQP i .�� � � �� �rYcssr <br />T.rCTIcA'\ OF,�l5.P1LL Bc.Ck�C Pn 51)), i; keSttC�� CCr cf�': <br />Pout. c cN< THen : c�t�. ca( 2,1; lctKe._ t' Sf Uf Inv 5 o�rillan <br />wiCs.1$Ue,Ke,T e� ��t�U�� ie�hnc` on v �, USS U'I��SStnc� fel 1 5 <br />9 <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION <br />CONT ACTORLICENSEII ICC'CERTIFICATIONP 4M <br />I certify that the information.provided herein :s true, accurgte, sad that the following c liditions have been satisfied: <br />The installer has metthe-requiremcats set forth in 23 CCR §2715; subdivisions (g) an(: ( ) <br />• The underground storage tank,' any' primarypiping, and any -secondary 'contaimmn was installed according to applicable <br />voluntary consensus standards -and arty.manufacturer's written installation instructions: <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, or°if required Ily .lie local agency, inspected and'certified <br />are ' fessionaI en ' eer Navin education and' ence <br />with unde uud Inra a tank em -installations. <br />SIGNATURE OFTANK OWNER OR OWNER'S AGENT DATE494• ' PHONE 467. <br />CERTIFIBR'S :incl 4Y5. CERTIF.IER'.S,T+►►R a6e. <br />489 <br />NAME OF TIFIER'S EMPLOYER (D33A) 48& CERTIFIER'S •REGAT10XL H ' TO. TANK OWNER <br />r 1. TAi�IIC OW7ek 2. TANK -OPERATOR <br />3_ coNnucrox . 4. PROPERTY OWNER. <br />1) :S. OTHER.AU'THORM 3) LGENT OF TANK OWNER ' <br />I1PCF UST -C Rev. (17 -007) =111 wwir.anidots.org <br />�?� <br />