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Sep 27 10 10: 54a Elite TV Contactors 12094616342. p. 1 <br /> UNIFIED PROGRAM.CONSOLIDATED FORM SEP 2 7 2010 <br /> €TNDERGROUND'STORAGE TANK' <br /> CERTIFICATION OF`INTSTALLATI.ON I MrO.DMC*WZGN j rOUNrY <br /> .. . ,. ::.��eform.Perp;o��t)..._.:.: ::.•: '.. •:. . :_., ..ENVinC3t�� :.,•.�A[_ <br /> CM <br /> FAMITY ID 1(Agency Use Only) r2 ffl- <br /> u• <br /> BUS S NAME(Same as FactN or g Ar) 3. <br /> BUSINESS'SITE ADDRES ti Ila <br /> v.1 /l� Pi. r ` J ttW. <br /> i�INNER- 7.'-.twW uk :�ttiv.'6Htt�^t0 . mofix•�s�-�C-,�,e�^...rva.�;.,..':; Oaa- M - �@:�s�, RFlv..a!... <br /> Y < ' <br /> TYPE OF PROJECT(Chet of than 4M WORKAUTHOR=UNDER PERMIT 483b•' <br /> .I.TANK INSTALLAMONORREPLACEMENT (Number or Dam):,. <br /> [3'2..PIPINGINSrAL&77oN:ORREELACEmo4r <br /> 0..3.SUMP INSTALLATION OR REPLACuMNT <br /> ❑;4:UNDERDISPENSER:CONTAINAENTINSTALL.4TIONORREPL:ACENIENT- <br /> 0 5.OTHER <br /> CR�nMOON-OR�WORS,BEING.CERTIFlED�._._,-�__.__��' <br /> cam„ Tt3 <br /> -5w�o& O Lrr .. tip L: �}} r C� <br /> � me.- d 2qu..;v•..F.G�-w"-6.m, -`�-a_..t'<�<-,:a.a.:t-k�e.mp�ry 3n,:zrr.,,..�,,,,y_-._.µ.'.br..�a-^sa.�sa;s.a,..,�.„-..w .4:c+:+`.s:•as ...�ks. 1� � trH <br /> Dvwwou <br /> "e <br /> K.r9... 6'ylk- <br /> NAME OF CONTRACTOR WHO PELFORME.D INSTALLATION I MODIFICATION 4 <br /> CONTRACTOR LICENSE JCC' 4U`- <br /> MQ <br /> at x o v e cmazw� i. <br /> xe- n _ <br /> y 1. <''•`G<T+.r: ,a.ri /, ..r.a..� t +;w:.p..+ �,i. . :.I.•. ,�'. ''dr 3b <br /> I certify that the.informaWn.provided herein is.trne,accnmte,and that the following conditions have been sads&ed: <br /> The insstaUer hasmet•thrreq�set•forth m 23 CCR-§2715,:subdivisiow(g)and{h)•..: <br /> The uadergrotIDd storage tanl� any primary Piping; and;a�.secondary containment;was iastalIed according to applicable <br /> - - volttatary-C=seB=--SMndards•and any mmu&cu=es written instalIalion znsnuctioas:: : . <br /> All work listed in the manufacttasr's-installation c6ecldistlsas been co;,vletede. <br /> D. The installation..has.been Inspected and.approved--by-the local agency.,or°if required.by-the local agency,insp-clod and certi5ed <br /> b a � rofessional ha. education and -erience with underground sto tank. em installations. <br /> SIGNATURE F T OWNER OR OWNER'S AG1T1I. DA 4" PHONE ep. <br /> . , - - ..�I'. :c �.�:•. --cam ���1 -� <br /> NAME OF 'S EM�7;OYER A)', : GERTMIER:S REL AITONSI�;TQ TANK OWNER <br /> TAI+IICOWNER:. --EL:2�Ti�MCbPERATOB <br /> ea➢. <br /> 3.CONTRACTOR. : .. 0::4.PROPERTY O WNER <br /> D.-5.0THERAUTHORUMDAGENT_OF TANK OWNER <br /> �x'r :IIPCF=- -C Rev.(I212007)--112 N-i-w.unidocs ors. . <br />