Laserfiche WebLink
Feb 20 14 09: 42a Elite IV Contactors 12094619342"j",j <br /> RECMIvEr. <br /> ... ... .. ... <br /> ITNl IED PR.0GRAM C0NS0LIDATEwr( Rm _ ;'' <br /> UNDERP�WUND`STORAGE TANI. <br /> CERTIITCATION OF INSTALLATION%]0 �DmCATEWiR0NMEN <br /> ...(Qne fo„rm.per projeci) HEALTH D�PARTME <br /> _ � gem � � "�•�1''x 5 • 3 X � <br /> CII # A Use Only) <br /> FA ITY ID <br /> BUSINESS eosF �— <br /> t ,, fsattt. nefltrylJanuorDBA. DoingBuritxvAs) 3" <br /> ✓- G+ I f <br /> �riujsINESS Sm <br /> ADD(RES$. 103. — 104. <br /> 1 a. <br /> ( r.,� � �,. �n. a �� � zh`:l�9?•r1s� �4 �.w.. P.av ac+an��rsk� S3 ;�. <br /> T iTE OF PROIF.CC�ed R at amply} bx °'d WOR UTHORIZED UNDERERMI1' A `r <br /> 4 . <br /> ❑ 1.TANK•INSTALLATIONORREPLACEMENT ;(Ni" orDaie), <br /> ❑ 2 PIPING INSTALLA noN'OR REPLACEtvtENT , <br /> ��3-.SLN&JNSTALLKMON OR REELACF1v1EN1• •UNDER DISP£NS£R CONTAINMENT]NSTAId ATION QR REPLACElv1LN1'OTIiF:R': --��/ <br /> }111 l6 <br /> DESCRk'TIONOF WORK BEING CERTIFIED: — <br /> GO <br /> 4. <br /> � / <br /> f <br /> Z OF CO R'WHO PERFO tIIdST. TION/MODIFICATION Y` asp <br /> CONTRA, 7i LICENSE# ate•,;ICC as2� <br /> �- <br /> 3111111, <br /> r <br /> Icer't'fYt6st the information provided herein is true,accurate,and that the following coi l:itions have been satisfied: , <br /> 'the installer has metthe - <br /> • _ requuemeats set forth in 23 CCR§271 ,subdivisions(g)ana:,h� <br /> • . The,underground storage tank,;a4Y.P�?ry PXPmg, and any secondary containmett- ras installed according to applicable <br /> votuntary:consensus•standards.and anycmanufacfurer's vritten insta]Iationinstructions: - <br /> • AII work fisted in die:d annfhdurer's installation chill ist has beca competed <br /> The rnstallat�on.has been;uispccted`and.approved by the local agency,or:ifrequred byy 0 :•local ageacY,i�aspeated and certified <br /> b a. istercd.` `fessional.en eerhavin .edncabouand- erience with under 'and st tank em installations: <br /> SIGTIATURE TANK 0 OR OWNER S AGENT aea:. PHONE DATE-- Q _ art <br /> C S NAME au" CER JEft'S TITLE acs. <br /> NAME 0 jCERTIFIER S EIvIPGOYER(DBA)' CERTIFIER S:REL4TONSHI P J TANK OWNIIt a� <br /> f ❑ I:TA�jK OWNER ! 2..TA�W--0PI R TOR <br /> GfC�l C C-CONTRACTOR I 4.PROPERTY owxER <br /> r. <br /> [I 5.OT$ER AUTHORIZED 4i ::NT OF TANK OWNER <br /> �t,l UPCFUST-C1/2 rww-uaidoci:org E <br />