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Oct 26 09 09: 48a Elite TV Contactors 12094GIG342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INST:ALLA?TON!MODIFICATION <br /> (One fcTM-. C'PmJect). ; <br /> FACn rry ID f(.tgeacy Use OalvJ NO <br /> 3. <br /> gIJ$ NA?d E(Sol/\ne�7s Name a DBd-DoengBeesiatss.Is) <br /> ;.•'. vv 164. <br /> BUSINESS D J� lay. CITY <br /> .syr 'ii a. :n .r—. ..;.:.�.:... 483x. UNDER <br /> UNDER PERMI? <br /> r.: <br /> WORI:AUIHORIZID <br /> TYPE OF PROJECT(Check 411 thatat;nlv). (Number-Dat-): <br /> Q 1:TANK INSTALLATION OR REPLACEIv1ENT <br /> .2.PIPING INSTALLATION OR REPLACEMENT <br /> Q.3:SUMP INSTALLATION OR REPLACF.tvIEN r <br /> ❑:4UNDER DISPENSER INiv1 CONTANT INSTALLATION OR PULACENI���l P <br /> : <br /> 493c. <br /> DE$CRIPTIOA'OF-WORK BEING CERTFFIED: <br /> 'OCT.2 6 2008. <br /> 8,AN`ja,;c�i�rty <br /> FNVIRO COUN71Y <br /> HFA' <br /> LTNOE ? L <br /> �,y�•3r,.•ie �_7�u!-..tra�v..sr z..e v.���rs,n+^cm G�t. >: •"i .�n4 a'J�r�. <br /> 110i ` <•'-c�rr+a'-� c 1..�.. L�.i F"il 'l.'•fxl * •e.�i..'�rt-.'�"3 <br /> PK'C p-q �. .... <br /> '•.• A z�x .a�b.r�;eiiwsa•n- we�e.a>�...s �•r...as:s..+. <82Z <br /> N F O CIOR WHO RMED INSTALLATION I MODIFICATION <br /> �•� � asp <br /> CONTRACTOR LICENSE# <br /> 4M' ICC CERIIITCATION <br /> 80 Z.L4 L4 3 <br /> ... _ yam. .ttEEi:�t . Ff :w. swA +.• O <br /> A T¢t S •'f�iFm 1 <br /> T certify that the Woruiation provided herein is true,accurate,aad 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.imdcrground.storage tanl� any primary Piping, and any secondary containment;Was installed according to applicable <br /> consensus standards.and auy:manufacturer'8vM ten•installatzOli instrnaraas: <br /> ' All work listed in the manufactu='s installation cheddist has been completed. <br /> The installation..has been inspected and approved by the Iocal agency;onif required by the_Ioca1 agency,inspected and certified <br /> b a i stered professional en ' eer having education and a enence with and and story a tank stem installations. 497• <br /> SIGNATURE OF.TANK OWNER.OR OWNER'S AGENT DATE .PHONE <br /> ��. <br /> .43S. <br /> 'S.NAI► (p ) CER S.TrME: <br /> Zviti 1 " 489. <br /> NAME OF CERTIFIER'S LOYER(DBA)` 4u, - <br /> CERTIFIER <br /> S.RELATIONSF7TP.TO.TANK'OWNER <br /> 1 TANK;OWNER-. Q':2 TANK:OPER:4TOR <br /> .'PROPERTY OWNER <br /> UTHORIZ3eD AGENT OFTANIC OWNER <br /> .5:0 rHER A <br /> ,�'.;: • ...CJpO'p'D5Y'-C Rem•(I�llOU.�-a2 .. : ""w'w'®'d°csor= -•.. - <br />