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Oct 14 10 09:08a - Elite TV Contactors 12094616342 <br />OCT <br />UNIFIED PROGRAM CONSOLIDATED FORM sA,V <br />rQ <br />UNDERGROUND' STORAGE TAN ✓r� <br />CERTIFICATION OF I INSTALLATION /'M0i2MCAWU* <br />' One form• er �ect f `'� :' '" +1 <br />®Yf ry`.. i.+e-+t 4, •i..`.Y''i'�' �.�,- ..1�.�-:C 14''i7< V}P�7Y��''+'W:.`Y(, h.�i+A l.P'd,lC.ee JSke0.id.'1J�Ane.7,.. 1"SiL ..'+?'..Y'�Yz #u'.A ,Z._ Tslu ys ,t E( •l <br />� -.x':- �'1 fit. r . -� i�`-h.s9.:.�= �Y,9 J.�'•�L t' ����L �a �Zn��`F � ..�-�n •^c4`l� L-?�, i'�`td+v:., ,+. c <br />• � _ y •.,%�,.F �.a'- .:n.. nem ;'+M:d..a .•�,^.-` .te-.Su-�.,,.'-x•+G+' _ �".T.. <br />FACLLfTY ID (Agency Use Only) <br />•BUS N IvMiSameasFadliry_iVmneorDBA—Dain B, Ar) . <br />Bus s srrE s. - � ,o.. <br />jj toJ.ve <br />--- - ---- --- <br />TYPE OF PROJECT:(Checl all i1,at annh l • <s WORK A=OR= UNDER PERMII' ' A&M. . <br />I] .1 TANK'A'BTAY-T (MON OR REPLACENI .(Number or Daft);- <br />[� 2.PIPING.INSTALLATION-ORREFLACEMENT <br />3 •SUW- INSTArr AMONORREPLACEN NT <br />:. 3( 4: T NDERDMPENSER'CONTAI 0AZ1.T TAiSTALLAI70N ORREPLPiCEMF1IVT <br />...: 5: OTiIER . ...-.. .. . . <br />—...._.-- ';DISCRIE'T10hLflF�N.OR&BEING.CIICGIFIED:-- - — - ...---_s. <br />?. —1 rte' -87 s4fi,3Nu 7' <br />rL ' Olu 3'LT� �,6&kA_ 1> 9 1 A u tj (A L `I , -w5P4-=QED pUT' 07F—j'4— <br />M1 <br />OF CO 'TRACTOR WEIQ PERFORMED JNSTALLAIII MODIFICATION 48h <br />CONTRALTO LI SE\.1 °st°'' ICC' �•.�J 1 �� <br />x30' "`.:: srv.1...�a;� " t•rp^`"^•j-i tom.. �„'` ,,r-.raY-�'" <br />F" ,xE..' ,:wwYiic '��`*»7t�"a3?r "i,+ K .`. """ <br />I certify that the inform ion.provided herein is true, accurate, and that the following conditions have been satisfied: <br />• `The installer has-menthe-regiuremmis set forth,in 4 CCR-§2715>:subdivis <br />• . The underground stora„�e •tank, any: primary .P� 6: and arty second . .'containment vas installed accordingto applicable <br />Voluntary: conwnsussta�dards-and at y,mhnufactarces *i:itten installation iastr sctics <br />• All worlrIisGed m the manufacturer's•iustaVAtion check[isthas been .completEd <br />•.. The installation..has.been.inspected and. approved tiythe_locat agency., or�if required'.by the Local aeency, inspected and certified <br />tered professional engineer.ha ' education and a erienc- with -arid and storake tank stem-insWIadoas. <br />SIGN A OF TANK.OWNER OR OVAiER'S.AGENT-- •DATE:-.' <br />- • lr�--�•:�� ao r �'�: - � 'y Cil. <br />.s _C.ER 's <br />�.4!�Lj <br />NAME OF CERTIFi1rR'S ENII'LOYER PBA) ' .CQ2Z[f:S.$ECAxIONS1EP TO. TANK OWNER 489' <br />Contra :T1tNKOWNER ©Q'42.TRA'ONPIiE'ORTPEYRO:4WTONRE'tfS.Jii2535 <br />U. S. 407AERA=0R= AGENT OF TANK OWNER <br />Sto �`r <br />VPCF-UST-C Rev �In 5206 wvrw.anidoe ;Z: <br />