Laserfiche WebLink
Rpr 02 02 10:42a Elite Iv Contractors Inc <br />UI1Wlil) PROGRAM .CONSOLWAnD FORM APR 0 2 2008 <br />U"ERGROU" STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATIqA JOAQUIN COUNTY <br />(One form per project) ENVIRONMENTAL <br />FIST, M"'DEPAR I MER I <br />I. FACILITY INFORMATION <br />FACILITY ID ft'(Agency Use Only) <br />BUSINESS NAME (Same 3- <br />Facility Name or DBA - Doing Business As) <br />IIN72�0 014 kas Fucilir <br />BUSINESS S17E ADDRESS 103. <br />FZITY. <br />3 ao -4- <br />11. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br />TYPE Of PROJECT (Check- all that =P1 413L <br />WORK AUTHORIZED UNDER PERMIT 48W <br />0 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />[:1 2. PIPING INSTALLATION OR REPLACEMENT <br />5p, 00 ��;-35-33 <br />[13. SUMP INSTALLATION OR REPLACEMENT <br />,014. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />3--1-072 <br />[] 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483e. <br />f <br />'r,e5l ecQ "'t Moi• -s c, JsA V <br />A &- - , -.7 - <br />III—CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION MODIFICATION <br />�e- I � COO jjg& kr5 1L. i-111— <br />CONTRACTOR LICENSE 9 1-21.1 <br />ICC CERTIFICATION # 42` <br />IV. CERTIFICATION. <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's installation checklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a registered Professional engineer having education and ex crience with undqgound stqLaae tank system installations. <br />SIGNATURE OR OWNER'S AGENT <br />DATE 434, <br />PHONE 491. <br />3 —1Xa - 0V <br />'14 /- 63 3 r7 <br />CEWTER'�PAMF (print) 485. <br />CERTIFIER'S TITLE: 486, <br />Ire 76A e—\ <br />C St <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488' <br />CERT]IFIER'S RELATIONSHIP TO TANK OWNER 489. <br />[:1 I. TANK OWNER Q 2. TANK OPERATOR <br />El 3. CONTRACTOR 0 4. PROPERTY OWNER <br />LJ'15. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UIPCF UST -C Rev. (1712007) -112 wvnyunidoca.org <br />