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Jul 17 12 06: 42a Elite IV Contactors 1209461&342 P. 2 <br /> Mrs <br /> • - p �t�{ a eg�..g,+IM BIgI]WAY . <br /> UNDERGROUND STORAGE TANK <br /> CER ICA'TI-ON OF INSTALLATION/M., )D CATION <br /> (One foram per project•) <br /> FACaM=M ID#(Agency Use Only) <br /> BUSJNESSNANM(sa.*ssacrrxa•srrrantMA-Doigaarioeas) 3 <br /> BUSINESS SITE ADDRESS mss. CITE' <br /> TYPE OF PROJECT(Check 493a WORJS f )THORIZBD UNDER PER3vIIT 49xa <br /> ❑-I.TANKINSTALLATION ORREPLACEMENT (Ntmtex n-Date) <br /> ❑.2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP 1NSTALLATTON OR REPLACDAE,NT 3 �-j J� <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT' ' 90 ✓ � `f't <br /> 5.OT IMR <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> MCE:. EAha &MPeiCIM "TO TMT I)CWLY 1531W.1— 'D MP Tti0t <br /> a <br /> NAME;OF CONTRACTOR WHO PERFORMED INSTALLATION(MODIFICATION' 4axe <br /> CONTRACTOR LICENSE# '2a'. ICC CERTIFICATION#• 492 <br /> I-cerbifyfihat tore iaf0 nalion• ravided-heroin fs�u secure <br /> it e, Viand-*at-the-foilowing-C)r hdons-have--been-satWed: <br /> • ' The iustaller.has.tnetthe requirements setfazth in-23 CCR X2715;subdiviszons(g)and(i) <br /> The <br /> + Tfie•imdsrgau . st<Eiage tank, any PT?m. '..... mid �Y secondary containment ras installed according to.applicable <br /> _ <br /> Voluntary consensus,standards and any ma-U tturer s wnttea tion ctlons. <br /> • <br /> All work fisted in the manufacturer's installation checklsst h*as been completed. i <br /> ® Th installation has.been inspected and approved by'the local agency,or:if.reiluired by tE local agency,inspected and certified <br /> b --registered rofesAonal engineerhav' education and eXpenence with under and st toga tanksystem installations. <br /> Q_ 4s� <br /> TANt4.t2WNER OR OWNER S'AGENT DATE. ._ :�sa,... 487.*•SIGN ONE'-- •.. , .. <br /> _ .. <br /> 704 <br /> -6657. <br /> $N (P&Q < 4CERTWM'S TITLE: Oft; <br /> NAME.OF CERT IFIER:S EibiYL4Yk2L(DBA) 4as <br /> CR �BRS'tEA1[0989[ Tk&OWER: 499. <br /> . <br /> 'TOR TANK OWNER d 12 TANOPERAEWWI N)f t y ° .CONTCTOR 4..PROPERTX•CWR <br /> ❑-S.QTEAU1iOZED4t <br /> ' <br /> ;?1TUFTAh'KOWNER . <br /> UPCIt UST�C-1/2 �- <br /> • - `$cv.(1212007) <br />