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Aug 17 11 07: 51a Elite IV Contactors 1209461 G3,nECEI ,�D�2 <br /> AUG 17 2011 <br /> UNIFIED PROGRAM CONSOUDATED F ►t�� <br /> UNDERGROUND STORAGE TANIs tNVIRONMENTgL HEALTH <br /> CERTIF'ICATION OF INSTALLATION/1h1DD"1Tf YNES <br /> .j0ne,form,per project).. ._.. . <br /> FACILITY ID#(,4ge>acy Use nh') <br /> BUSINESSNAME(SamecsFaciliryNameorDBA-DoingBusines&) <br /> Fina n w 50CLL <br /> BUSINESS STTE ADDRESS CITY — <br /> Co42i C V1 sol . IVG Lot!- �. <br /> � t � Y.yc p K '(�'+nk-z sr 3'ie ^1W:�s�tia .a�taxtRw�.i'. _._ r•n. 1 ; <br /> 7 <br /> Z _' �Y- �'rvsslh!A!ti4':�•9✓!;#. Md..'?'/-�.�-.:LSr r 1F.��',t!iArM. <br /> r"E OF PROJECT(Chwk•a!1 th 41-3° WOI:K .UTEIORLZED UNDER PEP 4ss� <br /> Q L TANK INSTALL ATTON OR REPLACEIvIEN-1 (Nuc�b cr Darc): <br /> Q 2-PIPING INSTALLATION OR REPLACEMENT <br /> ❑4.SPIDER STALL TION OR REPLACEMENT U t 1 ,�5 <br /> SER CONTAI N%IENT INSTALLATION OR REPLACE,= I V <br /> 5.0TF�R - — <br /> DESCRIPTION OF WORK BEING CERTIFIED; <br /> 4XX <br /> +ctV. if can d�-J (-;T, CA ,4 <br /> 3 ��11�ns <br /> Per fxic4c• cul' 10 V 5 kili , <br /> • jjjj� <br /> x/ <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATIONTION <br /> -— -- <br /> CONTRACTOR LICENSE# W-76 sszc ICCCERTIFICATION# <br /> 9... • ,j11,�^' k^; , W3R..4:Wk.i�+ � M/A'b :S 4�,� d r <br /> I certify that the information provided herein is true,accurate,and that the following CDI litions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and <br /> • the underground storage tank, any primary piping, and any secondary containment ras installed according to applicable <br /> voluntary consensus standards and any rnanufaCt urel•'s written installation instructions. <br /> • All work listed in the manufacturer's.instaIIation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or-if required by tt local agency, inspected and certified <br /> b a registered fessional eer havin education and erience with uadereround st riRe tank stem installations. <br /> SIGNA F 01�=OORR O WNER'S AGENTDATE — 494. PHONE 497. <br /> IER''(.S�NAM(print) 496. <br /> XL <br /> NAME OF CERTTFIER'S EMPLOYER(DBA) 48S CERTIFIERS RELATIONS ll'. I TANK OWNER 489. <br /> .0 1..TANK OWNER [ T�1�IRbPERATOR <br /> 3.CONTRACTOR [ +4.PROPERTY OWNER <br /> ❑ <br /> .5.OTHER AUTHORIZED,4C .'r OF TAMC OWNER <br /> UPCF UST-C Rev.(12;200 -I12 Ndoaotg <br />