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Oct* 08 12 12: 13p Elit- IV Contactors 12094816342 p. 2 <br /> I.INVUD PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTMCATION.OF INSTALLATION/MODIF EATION <br /> r#.• go M-M <br /> 11 fj{.r{Nj lFilPay. <br /> FACILITY ID 4(Agency Use OnlyJ.. <br /> BUSINESS NAME(smwaZAaZMNAME arDBA-DoinB=&1=t,) - - - 13.BUSINESS ADDRESS tai, C= <br /> 5; "4 <br /> �.'}�i;., -.. <br /> TYPE OF PROJECT(Check all that cooly), 483a WORK AUTHC R UNDER I'ERIvIII' <ssb. <br /> :13 I.TANK-INSTALLATIOROR.B.EP.C.ACEMENT: <br /> .❑ 2:Pn'WG INSTALLATION ORREPLAC r ' <br /> -❑ 3.SUMP INSTALLATION OR REPLAC:Eb1EN r <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR'REPLACEMisT1T' <br /> 'S.01�•IHR. _.. <br /> DESCMMON OF WORK BEING CERTIFIED: 404 <br /> IcJ iv-�Er�Ji2 <br /> C-C-d O ri rte_x nr_.fin u e.��-r a�n� a� .Z. - <br /> - fi-eco 'A3'1 iC�S.peeT� . car-tk .1 <br /> .rZ 4 <br /> 0_4`*3Y <br /> NAME OF CONTRACTOR WHO PERFORMED INISTALLATION!MODIFICATION riot <br /> CON7RACTOR'LICSNSE# 46� ICC CERTHICATION# <br /> 4 MOW 10514(.a <br /> �• �. - <br /> s <br /> I certify that the information provided herein.is_tr M accurate,..and.that the foliowing conditicm 'tl ve-beeti sitifiied-. <br /> • The installer has met the requirements set forth in 23 CCR J2715,subdivisions(g)and(h). <br /> •,.. .The.underground.stoJage_:tank,.anY 'primary:piping,-and:any- seoondary_coximient was it aalIed acFording to applicable <br /> - pa <br /> voluntaryconseinsas standards and any-manufacturer's written installation instrur,tions. <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.regvirod by the lora E gency,inspected-and-certified <br /> �, _ ered rofessiotlal en `neer have?-education and- <br /> CER_k..I._E1_LS_..NA3vlE(pdnt}' ! •_. ence,with p ound.st ` .-° j]k. -, <br /> installations: <br /> NATURO 3'HO <br /> nes <br /> �n. <br /> CERTIP]ER'STTTLT;c _ 4". <br /> r. <br /> . . ...._. ..__ _ .. .. ..- -. 499.. <br /> NA),E OF C.ERTIFIER'S EMPLOYER(DBA} C•ER11FI$R'S RELATIONSHIP :{?WEER <br /> ❑ 1.TANK OWNER ❑ 2 T. NK bPERATi7it <br /> �&3:'CONTRAC'TOR: F] 4:pI ;PEFftbY NER <br /> i7PL'F UST-C-'1R Rev.(IM2007}. <br />