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Jan 04 11 10: 01a Elite IV Contactors 12094616342 P. 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK JA�j ? <br /> CERTIFICATION OF INSTALLATION / MODIFICATI, ` 11 <br /> (one form per project). <br /> �. .. '�..J_. ,:L.tiL"< T..�. M m:� "'�•hnMY,,+••�._:.Y, -W� �i ti � la, _TY,k• <br /> � S.P�f�� � At,te,..u�.�,�,{ }.C2Y'3:2`.•�:f.'�.SL�"�-' ( 1. Y _ 1 '��itY,� h � �� — _ Ml+�i:. s.'%i_'... 'v <br /> FACILITY ID#(Agency Use Only) <br /> s. <br /> BUSINESS ijAME(Same as Facility Name or DBA-Doirsg�rMeA �l }�� � <br /> ] 1�+� �� t Jim ti((/, <br /> BUS ESS SITE AD SS 103 CITY �� <br /> �l��.i. •�.;� .. T :) 1�.7 <br /> MEN <br /> MIA <br /> + <br /> Shu ur?'.vy,N»., •'-_ ., �, ..r.. .,�;., <br /> TYPE OF PROJECT(Check all that annly) WORK AUTHORIZED UNDER PERMIT 493b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUN P INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONT_4INMENT INSTALLATION OR REPLACEMENT (J/ <br /> S.OTHER <br /> SCRIPTION OF WORK BEING CERTIFIED: <br /> /f -2 <br /> C! <br /> � L <br /> ` ltl 9 <br /> N <br /> ~N 7rR OP RM D 12jSTALLATION I MODIFICATION 4Ua. <br /> 4826' ICCERTIFICATION# 4s2c. <br /> C`6NTRACTOR LICENSE# �/' <br /> v� � <br /> t,'J74 <br /> ,�':•s ,�_3 r,{�.".. .+...s r .,�--,..,.Lv,:e;rnYs^n ��;4,y. s _ - <br /> m _.,• F k, a 'W .,�7 y..; �. t ����.��.:itati�w,M°�y�,'?�'i^ �=r.`�':i:�r:..:.�:'•''•.--r4 rtiti;fv�frl. xavia,..aS a.�ex :T <br /> I certify that the information provided herein is true,accurate,and that the followinor conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, 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 /> installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> b a ie 'stered professional en 'neer having education and ex erience with underr round storage tank stem installations. <br /> *CTIFIER'S <br /> URF O�TANK EROR OWNER'S AGEI\T DATE 4�' PHONE 4B7 <br /> 465. 486. <br /> NAME(print) CER S T E: <br /> �I'e C} r 1C <br /> 488. 489. <br /> NAME OF C RTa=nR'S F_.MPLO (DBA) CERTiFIER'S RELATIONSHIP TO TANK OWNER <br /> a � ❑ 1.TANKACTOWNER C❑ 2.PROP OPERATOR <br /> �3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(1212007)-112 wi+w.aoidors_o d <br />