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Oct 15 10 07: 10a Elite Contactors 1209461 -q4--7' p. 2
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> CERTIFICATION OF INSTALLATION!MODIFICt� 1N' `;'=SAL.TY
<br /> (One formperproject).
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<br /> IT
<br /> FACILITY
<br /> FACILITY ID# A _ a .
<br /> ( sir Use Only)
<br /> BUSAMme as F iry a or DBA-Doing Brsrinesr As) 3•
<br /> B INESS SITE ADDMSS 104•
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<br /> TYPE OF PROJECT(Check all that atmlvl 4 WORRAUTHORIZED UNDER PERMIT 483b.`
<br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Dam):
<br /> ❑ ?PIPING INSTALLATION OR REPLACEMENT
<br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT
<br /> ❑ S
<br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT `
<br /> ❑ S.OTHER
<br /> DESCRIPTIW OF WORK BEING CERT.IFIED•- ! 4s3a
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<br /> . OF° CTOR q RMED /STTALLATION/MODIFICATION W x 482a*
<br /> ,77 9
<br /> ONTRA�7ORIENZA
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<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 requirements set forth in 23 CCR§2715,subdivisions(g)and(b).
<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 checldisthas 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 /> by a registered professional engineer having education and experience with underground storage tank system.iastallations.
<br /> SIGNATURE OF TANIG;OWNER OR OWNER'S AGENT DAT 494 CZ )\ 437.
<br /> CERTIFIER S N1CMr;(print) - - aes. TTII E: asp.
<br /> i' -2
<br /> NAMEOF C LOVER(DBA) 469. CERTIFIER'S RELATIONSHIP O.TANK OWNER 489•
<br /> 1.TANIC O WNER ❑ 2-TANK-OPERATOR
<br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER
<br /> i ❑
<br /> 5.OTHERAUTHORIZED AGENT OF TANK OWNER
<br /> 1JPCF UST-C Rev.(1=007)-1r2 www.anidocs org
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