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May 02 02 11:49a Elite Iv Contractors Inc 2094616342 p.l <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />I FACILITY INFORMATION' <br />FACILITY ID n (Agency Use Onty) <br />BUSINESS NAME (SameasFacility Name or DBA — Doing Business As) 3. <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />IL INSTALLATION [MODIFICATION PROJECT DESCRIPTION` <br />TYPE OF PROJECT Check all that annly) 4131. <br />WORK AUTHORIZED UNDER PERMIT 483n. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />(NumberoDate): <br />jr <br />�i S S <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />'� 1 a j) <br />OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br />1. ti' � f" r'c:X G ( PU b W i�� l.�e tl�,r Roo -t- 'PLL~ S 4S 5& " l <br />5.c'. 14 '7 C c 1 '7 <br />' <br />7 <br />i-Y1,CJ�-ZLA. 7, <br />Cxr <br />II1. CONTRACTOR INFORMATION. <br />N OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />L l \Vr COQ '!`cu_!,r is nc- <br />CONTRACTOR LICENSE # 4826. <br />00 It (e C - fd <br />ICC CERTIFICATION# 4&2c' <br />y V 5 �, L_ 1 <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, 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 containment was installed according to applicable <br />voluntary consensus standards and any 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 by the local agency, inspected and certified <br />rfifi Ze d professional engnneer having education and ex erience with underground stora a tank s stem installations. <br />SI TURF OF K O ER O R'S AGENT <br />-- <br />DATE 484. <br />PHONE 487. <br />_. ✓ <br />337 <br />CERTIFIER'S NAME (print) 485. <br />CERTIFIER'S TITLE: 488• <br />NAME OF CERTIFIER'S EMPLOYER(DBA) DBA 4X8' <br />( <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489• <br />�,. <br />ti< (V rrc� i 1 t r'z�r F Gr J <br />❑ 1. TANK OWNER ❑ 2, TANK OPERATOR <br />❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (1212007) - 112 www.unidocs.org <br />