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Jan 18 13 01 : 00p Elite IV Contactors 12094616342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED F )RM <br /> UNDERGROUND STORAGE TAN t <br /> CERTMCATION OF INSTALLATION/VDDIFICATTUN <br /> • '.. '. ..:. .: ..(One formper:proJect):.__.: .• .: .. . . - <br /> j <br /> j .. a <br /> r <br /> L <br /> n'� <br /> i <br /> < <br /> FACILITY ID#(Ageney use 0*) <br /> SUSIN((E��SS NAME(Some ays�FacitirylJame ar�(D&4-DofngBusukn dsJ . 3. <br /> • t / l CJ �r1 " <br /> BUSINESSSITEADDRESS 103. CITY. .. ioa. <br /> PNO <br /> fez <br /> - _ 4 � •v �f <br /> .. - C$� �54Y• -do _t ntIW � J�K'ax+- `:^a.:- :a.:�,^-'M'�JrL©� �� _' � +�s'�.e-. �..�i�M1�a.:y. ��i�3•'1�• . <br /> TYPE OFPROJECT(0mckal1Charaonly) 4131,L.' WORN AUTHORNZED.UNDERPERbo' °B3ti- <br /> Q I.TANK INSTALLATION OR REPLACEMENT. (Nr m :rot Date): <br /> J],z.PIPrNG INSTALLATION OR REPLAcEv Ew <br /> 03.SMR WSTALLATTON OR REPLACE&IENT <br /> Q 4.UNDER DISPENSER.CONTAIIdME IT INSTALLATION OR REPLACEMENT'. + <br /> D 5.0TT4ER. <br /> ---- —• E5CRRMON10F-W0RK BE)4G.CERTIFIED�-.� <br /> CYIe, w1=t�t5 u ` on . srl ' (1)i}i t5� 'e ;S �ri5�1�d. <br /> � Cedq- rw� -h­jdyo �AG�icj Win_ 600-- *--ICH; wao - �n hts <br /> RnY1ui[ ',-� �k1ec Sic` �jt'C StYZc>11 <br /> -�� <br /> Yo-r. - - _`'lt'- ...� .�.. � •o�_ �ry. r - s=ue 'g,'�m c. L c. ,.r "-x.mey <br /> . r <br /> ;n _,."'w :,:i.'.f'Ai av�wwvar�ca -; ,.z:.— :..rm��a•�w:. a '". 4�. <br /> T <br /> NAME OF CONTRACTOR'WHO PERFORMED INSTALLATION/MODIFICATNON _ 4S2�. <br /> CONTRACTORLICENSE# �i CL UC��j Co A 6 40 rcc'CEIUMWATION j 4Q.. <br /> - <br /> : y <br /> I certify that flee infore3iation.provided herein is,trne,accurate,and that the followiu; a:nditioas have been satisfied: <br /> • Theiastal(erhas:metthe requirements setfortiz ia23 CCR'§2715.,snbdiaisions(g)and E). <br /> •....The uundergrouhd storage innk, any'primaiy.piping;and:any secondary contaimtie t:was instaAed according.to applicable <br /> vohmtary consensus standardsaud-any.:manufacu er's written installation-instructio> <br /> of All.work listed in the mantrfacturer's-installation checklist has-been completed <br /> . The installation hasbeen_inspected and approved�by the local agency,or-if required b the local agency,inspected and certified <br /> a•' stered rofessional ecyn eer.having education and menence with UndmgroLastoraugeteakwstem nnsw1ations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT , DATE. _484.- .PHONE 497. <br /> CERTIFIER <br /> N 1 .40. CERTHmwS.TITLE: sae. <br /> t - <br /> Ll <br /> NAME OF TIFIERR'5 EtvIPI OYER(DSA) CER1'll�lt'S 1tEI ATIOTI iI I',1 O:TAIQK'ORTIER <br /> . , ��.t l�� �.c`�l�pr�.�d�ZZS� ��C., - -� is rANIC'owNER`-'' C- z TAbrERnTox - <br /> 3_CONIRACPOR ❑ 4.PROPERTY OWNER <br /> • .. ❑ <br /> S.O.THIRAUTHOTCTi.'E7 AGENT OF TANK OWNER <br /> rx' U?CF'US'T-C Retie.(1=007)-112 www.nnEdoesorg <br />