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Jun".20 12 10: 20a Elite IV Contactors 120946J&342 P. 2 <br /> qP <br /> UNUFM <br /> PROGRAM CONSOLIDATED F(!1 i1 <br /> UNDERGROUND STORAGE TANK <br /> CER CATION OF TINSTAL3LATION/:h'[CIDMCATION <br /> FACHZff.II)#(Agemiey Use Only) <br /> . .�. 3. <br /> 13USIF7EiiSS NAME(Same aslFacfUrytName�DS.1—DatngBusir�ss ds) <br /> BUSINESS SITE ADDRESS to3. CI11' Baa. <br /> TYPE OF PROJLG7(Check all iv) 493- WORE.. l�THORI MD UNDER PERMIT . <br /> rl 1.TANK INSTALLATION ORREP1 ACEmENT. {hhm»e c:Dxte): <br /> M.3.PIPING <br /> INSTALLATION OR REPLACEMNT <br /> ®.4.UNDER DISPENSER'CONTA DMMT I TST_A.LLATION OR REPLACM.MgT <br /> D5SCFJP7n0N.OFW0RK HEINO CERT11113M: <br /> ? - i n� : h ctv�s ccsiti z� <br /> tom,, <br /> b <br /> Pis f i Lei. <br /> NAI�tE OF CONTRACTOR WBO PERFOR]uIEtI)��INSTALL.ATION I MODIFICATION _ spa <br /> t .l6, KDC _ .. <br /> CONTRACTOR LICENSE# a IC•CERTIFICATION 4 <br /> I certify that the inf®aaiatioiB.provided herein is.trne;aceturate,and that the following mditions.hsve been saeisfted.: <br /> Theiusstalier has lnet the regtullents set forth in 23 CCR§2715;subdivisions(g) <br /> and a). .. <br /> The urideigmund storage taul� anY_PzY PIPimg;slid any secondaay contanmie t was installed according to applicable <br /> Voluntary consensus standards and-any manufacturer's written in taIlatior<i ust<uction:. <br /> Allwork listed.in the man s.iaslallabon zhecldist'hw been compteted. <br /> The installation..b2s been inspected and approved by thelocal agency,or if,required I7 'he local agency, ed and certified <br /> a tstered . fessional eerhav`m educatim and ex enience.with undemProtn ;ata tank installations. <br /> SIGMA. P T O R WNER S AGENTDATE / ass PHONE <br /> C$R 'S'NANII:(print) T1FIERRS TM <br /> Z' <br /> CER Z' <br /> 489. <br /> NAME OF CERTIEI!'�t'5'EI+9PLOYER(DBA) <br /> `� CF.XIUgEWS REL:ATTOIi.`S IP TO TANK.OWNER <br /> 1 F_ I owI IER': I� z Tri OPEIutTOR <br /> 3.CONTicACTOR: 4.'PROPERTY OWNER <br /> .5.amm AUTHORIZE �AGENT OF TANK OWNER <br /> 'mlm U5T-CRev.((=W7)-1Yt w noidoes org - <br />