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Aug 22 12 10: 21a Elite-.IV Contactors 12094 342 p. 2 <br /> w <br /> UNWIM PROGRAM.CONSOLMATED F IRM <br /> 'EJNAERCRQU. D STORAGE TAN; <br /> CERTIFICATION OF INSTALLATION!A "IDDIEFFICAI'ION <br /> FACULITY ID#(4.wy Use Only) <br /> BUSINESS NAME.(Some asFacillry P/adpe DBA-Dobrg Bushress As) 3• <br /> r10( <br /> BLtSIIQESSSITE ADDRES5 103. .CITY- ,oc <br /> .Lod t <br /> • a H <br /> TYPE OF PROJECT(OwkaWmt W9 iWTHOR]ZED UNDER PE IIT ' <br /> ❑ r.TANK INSTALLATION OR REPLACEMENT. ... {Nu m r oQ Dau): . <br /> [j'2.P.I1'IhIG SNSi'AZ,LATtOId ORRF.PLACE1�JEf�'!' <br /> E3-3.SUM['INSTALLATION OR REPLACDAENT <br /> 5.anER <br /> ;❑.4.UNDER DLSPE NM CONTAII�N'T INSTAL LAnoN OR REPLACEMV NT <br /> _-DESCItaMON-OFWORK-BMNG.C&RTIF'.ED:_. _-- <br /> on :c�l"�C-; `�' 2 t ,2' �� ` <br /> Midi le6 <br /> t 1ct5 C 1C�C�d_wink) CQYYA) f�+h - ccc <br /> tc� rkNj mdhwc PCank <br /> NAMEOFCONTRACTORWHOPERFORMED INSTALLATION IMODIR Anon <br /> CONTRACTOR UCENSE# / //��. 4SV2& rcc c£RxTIFICAxroN'l• L��i�'Al '0`' <br /> I certify that the'information pri`i jded-herein is,tree,accurate,and that the f®Ilowinj:i i tditions'have been satisfied: <br /> • The'mstaRer'hasmet the '. is serfor&z in 23 CCR§2715 'subdivisians W aa.i I►. <br /> • , The and d.storage.tank.ally arty.primary,.P�g, and arty secondary conteirm a :'was instatled according to applicable. <br /> _�.vohuttarJ,,.consertsns= nd'a>ry;maz�fac4crer's'wtxtten." ` 'tion-instiuctioas <br /> comp., <br /> • AlIwozkLsteci'iritlieuianu#'act�uer's-iizstatlatioric�3isE'hasbeencv Ieted - • <br /> • The,installafian:has.been iisspected and.approved'by'the lecal•ageacy,Or°if :r� fie Iocal agency, ' and c�6ed <br /> b .a rofessia�al ea ' 'havin eduiitibnand _ 'ence with under u3c nota tank seem-brstalMons. <br /> SIGNATURE OFTANK OWNER OR OWNERS AGENT. DATE 44 PHONE . <br /> L_ <br /> CERTWIER'S N ' �N ,CExTMER.S.'�x�L� «. <br /> NA&OF 'S EA910YER.(DBA) : CERT-MIER'S RELAATIOAN;�H 'To TANK OWNER <br /> ( ��'j /f, c� ❑ LTNKOWNER ❑.'2 I"ANK-OPERATOR <br /> a �]-3.CONMCrOR i7 4.PROPERTY OWNER <br /> 13.5.OTrIER.AUTHORMIT %GENT'OF TANNIC OWNER` <br /> c x UKT UST-C Rev.(1 M7) 7/2 Yr[9Vc'AAfdPCS 4Yg <br /> } } j <br />