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JL11'8 02 08:52a Elite Iv Contractors Inc 2094616342 p.1 <br />.0., �+RECEF'1V0 <br />J <br />UNIFIED PROGRA.M..CON SOLIDATED FORM <br />SA/V,/04QU111VC <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION 1 ODIFICA �EpA,A1,U//VTy <br />AL <br />(One form per project) /�j <br />ZNFML FAGT <br />FACILITY ID # (Agency Use OnhJ <br />1 <br />1 <br />1;:: t <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3 <br />eo L,,2 <br />BUSINESS SITE ADDRESS 'a3• CITY <br />.-- 1 <br />1;1C.J � �- f' t✓� L''?'}'�Gt`il G� 41 Lei. <br />11.: INSTALLATION / MODIFICATION PIt(}JECT:.DESCRIPTTON <br />TYPE OF PROJECT (Check- all that annJv) assn <br />WORK AUTHORIZED UNDER PERMIT a83b. <br />[3 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />OR REPLACEMENT <br />� � T I / <br />F]4. UNDER DISPENSER CONTAINMENT INSTALLATION <br />-. OTHER <br />DESCPTION OF WORK BEING CERTIFIED: � a83c. <br />RI <br />ee w 1 �► r 15 Cc�.Ccp, <br />III .CONTRACTOR JNFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 4820- <br />1 <br />ELA Z. x ; n 6C .rZC:._ <br />CONTRACTOR LICENSE # 482b' <br />UG— f-'(' � �+' % �C -H <br />�Z` <br />ICC CERTIFICATION # <br />5 <br />'M,,. CERTIFICATION.. . <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• All work listed in the manufacturer's installation checklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by q registered prof *onal en ineer havin education and ex erience with underground storage tank system installations. <br />Qe <br />SIGN EL WN TCOWN`E�R S-A EI <br />DATE ata. <br />487• <br />(PHONE <br />-�RTIFIER'S NAME (print) �- 485' <br />C- <br />CERRTIFIER'S TITLE: g 489. <br />1.t i�K' U i i:� f7 �►Y� <br />NAME OF CERTIFIER'S EMPLOYER (DBA) a88. <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br />'ol Cc 'rS E r;�,- L -far S �' ��' <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (1.212007) -112 www.unidamorg <br />