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Mar 09 12 11 : 17a Elite IV Contactors 12094616342 p. l <br /> UNIFIED PROGRAM.CONSOLIDATED 6 RM <br /> UNDERGROUND STORAGE TAMI- MAR 09 )j , <br /> CERTIFICATION OF INSTALLATION/:V ODIFICATION-' <br /> I MAN <br /> FACU ITY M#(Agency Use Only) ?•»t w R�3�;� ' <br /> I.BUS S NAME(Same as FariliryName or DBA=Doing Busb ss As) <br /> BUSINESS SITE ADDUSS 17(X. <br /> r,, <br /> • °i''., ... ..:.ti-�A• ..-a... mNe..�.a.m.ro�a, fic .. F ># i s <br /> TYPE OF PROJECT(Ch ecP all that annlvl 4&3z WOF-K UTHOR=UNDER PERMIT assb <br /> ❑ 1.TANK INSTALLATION OR REPLACEIvIEW (Nnr ib •ar Dale): <br /> ❑ 2.PIPING INSTALLATYON OR REPLACF.ME'NT <br /> ©'.4.OTHER ST ENsE c OR wmENT WST <br /> ❑ 4.UNDER DLSPENSER C:ONTAINMEN't'INSTALLATION OIt REPLACEMENT 7 <br /> DES ON O WO EING CERTIFIED: Ae <br /> rrw. _ <br /> rA <br /> 3f. �' .... "1*it�"<<`nM.... .. -a3�r �svuxk�A��rn'.•P,a�'S7���� � $._•-t,��_�.Y•.4ti- �..�?n��� lY+; <br /> 9F OCTOR. ( PERFO INST TION!MODIFICATION 4sxa <br /> NTRACTOR LICENSE# ; ` // `/ (/'✓ <br /> _ _ <br /> .� � a:?f�lT��j <br /> .hffi+:-x n.•� _ .A WEmm Y� '�"tiY-T�.i£•� (..' Q�',��'.'':TiF 6�"'T"9'- }'i <br /> I certify that the information provided herein is.true,accurate,,and that the following :c i ditions have been satisfied: <br /> • The installer has met the requirements set-forth m' 23 CCR§2715,subdivisions(g)and(I <br /> • . The undergroundstor age .tanic, any primary piping, and any secondary containmeai vas installed according to applicable <br /> voluntary consensus.standards and any..hanufacturces written installation instructions. <br /> All work listed in the mannfacU er's_installation checklist has been completed <br /> The installation has been.inspected and.approved by the Iocal agency,or-if required b;r i ts:Iocal agency,inspected and certified <br /> b a:' "stored. rofessional engineer having.education and a ence with and IM41! Erage tank' em installations. <br /> SIGNATURE OF TAMC OWNER'OR OWNER'S AGENTDATE PHONE asa <br /> .ss. cER' "TrTLE j 4W <br /> ola'i <br /> N 0 CEIZ1'tIMq-S DYER.-MBA).:'' . : � : CIItZIFIER'S RELATIONSf II [O TANK OWNER.. .. 489. <br /> t / : l.. <br /> r 0. ,TA3�IICOWNR' ')'"2Tf�IKOPERATOR' <br /> ..❑ 3..C:O]WIPA.CTOR -1'4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZE[-E i ENT OF TANK OWNER <br /> e i .. UPC F UST-C Rev.(111ZOU7)=L2' �eww.�idoe-o <br />