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Jul 16 09 11 : 52a Elite IV Contactors 12094616342
<br /> UM[FUD PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> CER CATION OF INSTALLATION/MOD CAT`S f''"°` U1 COUNrY
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<br /> FACILl1"Y ID#(Agency tlae Only)
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<br /> BUSINES PEE tai. . � tan.
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<br /> TYPE OF PROJECT'(Check a1/thar aerolvl 411Q. WORK AUTHORIZED UNDER PERMIT 483h..
<br /> ❑ t.TANK INSTALLATION OR REPLACEMENT (Number or Date):
<br /> ❑ 2-PIPING INSTALLATION OR REPLACEMENT
<br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT
<br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT
<br /> ❑ 5.OTHER
<br /> DESCRIPTION OF WORD BEING CERTIFIED: °
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<br /> lIN'STAL TION! ODIFICATION 482x.
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<br /> OR LIgENSE# ° ICC'CERTIFICATION# 4&2r.
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<br /> I certify that the information provided herein is true,accurate,and that tate following conditions have been satisfied:
<br /> a The installer has met the requirements set forth in 233 CCR§2715,subdivisions(g)and(h).
<br /> a The underground storage tank, any primary piping, and any secondary containment was installed according to applicable
<br /> voluntary consensus standards and any manufacturer's wrifen installation instruetions.
<br /> • All work listed in the manufacturer's-installation checklist has been completed.
<br /> a The installation has been inspected and approved by the local agency,or if required by the local agency,inspected and certified
<br /> a 'stared professiojial 2g ' eer Lavin education and cmdence with and and stn tanksystem installations.
<br /> SIGNOF TANK O S AGENT DATE 454• PHONE �•
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<br /> .. CERTIF NAME(print) aMS. CER 'S � , 49&
<br /> NAME 0 PLO (DBA) 4�' CER S RELATIONS TO TANK ER 489'
<br /> ❑ I.TANK OWNER ❑'2:TAW'OPERATOR
<br /> ❑ 3.CONTRACTOR D 4.PROPERTY OWNER
<br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER.
<br /> UPCF UST-C Rev.(12/2007}-1/2 ee+vw unidecs.org
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