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Dec 18 13 12:01p Elite IV Contactors 12094616342 p.1 <br />HEC..E1VEQ <br />1p ' <br />:UNIFIED PROGRAM CONSOLIDATED F }RM 1. 8 2013 <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION? t P CODIFIC�t.NM�N~j-�L' <br />HEALTH DEPARTMENT <br />(Age' Use only) � f <br />»�1 YW 1. <br />BUSINESS NAME (Same as Faeili Name orDBA — Doing Businw As) <br />. C:U'�T�i�uY.i <br />BUSINESS•SITEADDRESS [03.. CITY. — fpa <br />t>J�T�c� R0, STc)GKT: <br />' ;� _•-n *-'� «r a, +� . � � - ..v:r• 9��. �R1TTi+� JTJ'�19�5�f., k• a <br />TYPE OF PROJECT (Checka that RRjvl 493L WOU AUTHORIZED UNDER PERMIT482t. <br />❑ 1. TANK INSTALLATION OR REPLAMIENP <br />[32. PIPING INSTALLATION OR REPLACEMENT <br />©. 3. SUMP INSTALLATION OR REPLACEMENT ` <br />D 4. UNDER DISPENSER.CONTAMTENT INSTALLATION OR REPLACEN ENT <br />t'c1E,1 �N� �p zc�2.r� crtec Fun-tttJnw��mc c w T. �:w -r <br />LUCATU int 'tom LacA7(im Cc (t a i2fi.(tval W51V t-1 -050M <br />1 N.AIVM_t9E.�Or.F.-C. OaN''fTlRtACTOR 7 <br />wMvMOUTON <br />WHO PERORMED INSTALLATION MODIFICATION <br />CONTRACTOR LICENSE # / / t! _ 4n. _ <br />C <br />CERTIFICA77IN i 4M ' <br />,.Ni4>• <br />I certify that the information provided herein istrue, accurate, and that the following c editions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715; subdivisions (g) ane { ). <br />• The underground storage tank, any prunary piping; and any secondary containmlm was installed according to applicable <br />voluntary consensus standards and any.manufaetumes written installation instructions,. <br />• All work listed in the manufacturer's instailation.checktist'has been completed <br />• The installation has been inspected and approved by the local; agency, or•if.required by ie'local agency, inspected and certified <br />by a •'-stereci ear rofessional ea ' haven education and experience with and urd cora a -system,inStAtIlations. <br />SIGNA F TN O R WNER'S AGENT01 +DA PHONa97. <br />(print) : TIF16R. S.MLE.- 496, <br />1 <br />NAME OF CERMER'S'EMPLOYER (DBA) 49$ CERTiFIER'S RELATIONS: -11 TO.TANR'OWNER 489• <br />ELiTE_Mconnpaol 5.� i.rA�ucoWNER p:.z'r oP RnTOR <br />3. CONTRACTOR .. ] 4.PROPERTYOWNER <br />S.01HUAUTHORIM). GENT OF TANK OWNER <br />UPCF UST -C Rev. (122007) - 142 www.naidaa ort <br />