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Mar 0?, 10 10: 13a Elite TV Contactors 12094616342 p. 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> 3. <br /> BUSINESS NAME(,,Same as Facitizy Name ar pBii—pourg Bw�ncss Bsj �:,;;,�- <br /> BUSINESS SITE ADDRESS 1e3• CITY <br /> TYPE OF PROJECT <br /> (CI1e1k all fI74r <br /> 483a WORK AUTHORIZED UNDER PERMIT' 4d3b... <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMEA'T (Number or Date): <br /> Q 3.SUMP INSTALLATION OR REPLACEMENT C, <br /> ❑ 4.UNDER DISPENSER COIQ'TAINMENT INSTALLATION OR REPLA1 <br /> �.5.OTHER CEMENT <br /> DESCRIPTION OF U+ORI:BEING.CERTIFIED: <br /> aS3c <br /> iU A I CY1 • c SCic Tc� vtfY G SYS }t U 6 c�Pt►� �1-+50 0���� <br /> �Y-,c TE5T- (6-7j <br /> P�s�rn <br /> h:F�.�v'•��." ; VA'r•°�7,'F �� � W i ll;^''{'y1'7"v .. Y 4 .�. <br /> f <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION�. , ������ s��t '�� � � ei. <br /> 492a <br /> CONTRACTOR LICENSE# _ °�' ICC'CERTIFICATION# GI , v Q� <br /> '_'`'.�%Ir A�.'mow.C+,+'.�. ��'WSSr .k+a: 1 l� S l l L u.J <br /> `"xr'n �' .ts'•_«3.i+s�''k. l as a:i.:'„ i <br /> yam+ } �%�` ,y ` T.■y�. l.. .... G <br /> ..Y....F M�::.-.{�C...!?I yf Xy ..�'F��C..:�:' �J��1.:�Y•.(JdS:;Y�N1 ���LYLY ��>Ch�F ,rl�,�5� SI::. R���,�. -;,N, 'E �'_ <br /> r ..�.,�. ......_ i....:, M".xk.t'' <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 requirement,set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank any primary pipinS, 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 /> b a registered professional enl;ineer having education and ex enence with under and storage tank stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGEI\T DATE asa. <br /> PHONE 497. <br /> CERTIFIER'S NAME(print) 4x5. <br /> — CERTIFIER'S.'TITLE:12 , b6f.I <br /> 466. <br /> NA1vFc 1OF CERTIFIERCUM <br /> S EMPLOYER PBA) 49 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> co t �\}\l� 1,CJ�j t ❑ 1.TANK'OWNER Q.2.TANK'OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12r2007)-II2 <br /> www.anidocsorg <br />