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Dec 17 10 10: 26a Elite IV Contactors 12094616342 p. 1 <br /> i <br /> UN1FMD PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGF,TANK <br /> CERTIFICATION OF INSTALL-A TION I MODIFICA7 TONN 2010 r <br /> Form:Faita.: <br /> FACILITY 1D R(Agemcp Use Otd) A i S TH �; ' T<,.r'T Yrs <br /> BUSjNESS NAME A m mF.adUlyName or DBA–DoingB=marsAsJ 3. <br /> i <br /> BUSIN SITE AD SC[TY 104. <br /> 4 M. <br /> GA,� <br /> :.. �q y._'_. �t •.r.+ .wt: !S!lG+a. Ion _.!A°p' .-N <br /> L e kVV,, <br /> TYPE OF PROJECT.(Check alT that armly) 4e3c., WORKAU=MORT UNDER PERmAT '49 <br /> op 1.TANKiNSTALLATION OR REPLACEKIENT, {Number or D*)-. <br /> Q'2.PIPINGINSTALLATION'ORREP.LACE VT . <br /> Q..3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑;4.UNDER DISPENSER'CONTAMIENT INSTALLATION OR''REPLACMVM <br /> �3 <br /> Q 5 OTBM <br /> --- ESCRIP-nON_OF1V-ORr B£TNG-C ZT.I&LER:— <br /> ? r� _ W.s-w.# rr� YL�y t4 i—�*±7/2� x•'.fbrt .a; tr..,.c:�'z r a .a <br /> :�`"`+R`•t4 veM AC. <br /> "f � •, Yx.,s�' is:i3'? '3'+�`'srk�'.w;+�.�t'-'rr�'4-�„ <br /> k' :k�SL'.$ii.:.��.:' h�.' ,. _a�.�,..!� �E.ri�ro.uHa....a;i:,e7.,. ..�a.•- ...elet_-? .l+' _.w!,."yv„w n_ a:sr S'my. ..:ti-. <br /> N CON�CT•OR WHOP QRNIED INION/ ODIFICATION . < <br /> CONTRACTOR LICENSE# ° ` ICC•CERTTFICATIONV <br /> ..r�.�+,��y�� ,�. ��� ��k ��'r ���•+R�r'���i::'aa`,��4�W"�.��"�� sd��.}ir .i'a�aly.:z�.,,a ro�. �i�y <br /> .Ln C� ItAA ..1 �.._.�_'G.v�S•9��X II:x: <br /> I certify that the,information provided herein is true,accurate,and that the Mowing conditions have been satisfied: <br /> The-iastaller'has met-the requirem set forkh in CCR'§27.15;'subdivisions(g)and(h):' <br /> do The underground storage tank, any primary.pipn�g, and.any 'secondary containment,was installed according to applicable <br /> voluntary'consensus-standards-and any.manufacturer's written instauation:insfrUctions.' <br /> All work listed in the mannfact�er's-installation checHist has-been completed: <br /> .. The installation.has beeQ inspected and approved by the Iocal agency,orlif aequired.by the local agency,inspected and certified <br /> Waxegistcred rofessional engineer havineducation and a enence with under und.stora tank: m installations. <br /> SIGN TU�cE OF TANK OWNER ORO 5 AGENT DATE PHONE. - <br /> M11A- <br /> jjQ,)a <br /> .TITLE.OF CERTIFW'S MAPLOYER .:4 a 'CER; REi:ATIONSHIP TO.TANK OWNER 419• <br /> "Q`.I.TANK OWNER ©"2 TAT•1R OPERATOR <br /> Q 3.C ONTRACTIOR Q.4.PROPERTY OWNER <br /> )] 5.OTHERAUITiOR1ZED AGENT OF TANK OWNER' <br /> =! 1T3'CF'UST-C Rev.(12=07)-Mirnw.nmdocs.or d <br />