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Jul 11 12 12: 24p Elite IV Contactors 120946 342 p. 3 <br /> o e <br /> UNW IED PROGRAM CONSOLIDATED F I RM <br /> UNDERGRCIUND STORAGE TAMC <br /> CERTIFICAT14ON OF`INSTALLA.TION l VSOD CATION <br /> FACILITY ID#�itgency Use Only) <br /> BUSINESS NAX E(Sense as Facilfry Name or DIU—Doing Basmese&) . . a. <br /> BU S SITE ADDRESS im. <br /> CITY �t - ..� - . �-1,�•,G..�. <br /> nj <br /> TYPE OF PROJECT(Check al that annly? °m+' WO CB ^.UTHOR=LINAER PER1,�L[T : 483b <br /> D,1:TANK INSTALLATION OR REPLACEMENT. <br /> Q-2.PIPING INS7ALLATION•ORREPLACEMENT <br /> Q,3.SUMP INSTALLATION OR REPL.A�+iT. <br /> ®:4.IJJ�IDE R D SPENSER CONTAIIdMENT IllTSTALLATION OR REFLAC�NT <br /> Q 5-allm — <br /> D.ESGRIPMOKOF_WORKZiEING-CER.TdF1W:-M___.._._. __ . __..__— i_..,_�::_ .a— _ _.----_- --.-•--..-----.-- -- _..__.._.__:__._.4&3c . :.__..--- <br /> - f x I. ` cl�c)� <br /> t , <br /> ..� 0t� e <br /> NAM E OF CONTRACTOR WHO PERFORNM WSTAL.I.A7ION.J MODIFICATION — 4104 <br /> CONT UZWR LICENSE# '. ICC:CERTMCAT10i— 4m <br /> Milli <br /> i_certify t"t the information. provided herein is txue, =orate,and that the follo9ving c, o:ditions have been satisfied: <br /> ® T'he installerhas met th i�set fordI is 23 CCR§V15'subdivisfons(g)ffid( ! <br /> •..: The pa <br /> dergrouud.storage tarsk, any p Y.pipmg, and any secondary 'c�ntainm�n was installed accarding.to applicable <br /> .voWgary c ... . -nd-any. 's written iaistallatioainSh:cdms. <br /> woxk'listel the mann <br /> s- on ctleoklisf has been completed <br /> •; The instatlafiori:bas-been mspected and appsOved:3iy the IOc�i agency,or if regiiired".hy: ]e loci]agency,inspected and certified <br /> by a•ke 'stered rofessional " e 'M and e'fence with and.. tend to instaIMow. " <br /> SIGNATURE OF TANK OWi�tER'OR OWNER'S AGFa+iT.::.. DATE — s& PHONE sen. <br /> NAME(auintl, -. <br /> CERTItt'S _ 4 <br /> NAME <br /> OFCERTIFIERS EMPLOYER(DSA): CERTIFIER'.S:REI:ATION5:It 'CO,,TANiC'OWNER °�' <br /> ®;I:TANK DWNER []-2 TA'�IIC�fPERATOR <br /> CONTRA , <br /> r] 3.: . . {TOR :] 4 PROPE[tTY OWNER <br /> kC <br /> . i iEI1T OFTA]�IC Ow1+1FR'' . <br /> ... .. J.. .S:Y?TI�..R AUTFIORIZE:! . : .: <br /> r k° UPCF UST-C Rev.(1 17+A87)`In, www daesorg <br />