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Jul 8 02 08:52a Elite Iv Contractors Inc 2094G19342 p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />ID # (Agency Use Oaw <br />e - <br />L'` <br />as Facilitv Name or DBA — Doing <br />TYPE OF PROJECT (Check all that anylyl <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />CL <br />WORK AUTHORIZED UNDER PERMIT <br />(Number or Date): <br />(-!-c;, �q' LI -1) :.��.�-C�;�r� �, C c •C. L ! <br />// (,►-�._ �..��;z-� �',:�LrG7- .;� �t� ter,. ���. t �` .�'i <br />1-11P Ur wyiv t rtn�. Ux W HU t't:.KFVKMED INSTALLATION /MODIFICATION 4M <br />CONTRACTOR LICENSE #°4-6. ICC CERTIFICATION # 482. <br />A <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 a registered orofessional en 'neer having education and experience with underground storage tanks stem installations. <br />SIGNATURE OF TANK WNER O WNER' E DATE 494• PHONE / ? 497. <br />�;1, i'� •� , i� % _ L; (,moi i ) i I — [c J 3J� <br />CERTIF,IHR'S NAME (print V185 CERTIFIER'S TITLE: 496 <br />Q-�-:r u <br />NAME OF CERTIFIER'S EMPLOYER (DHA) 4 CERTIFIER'S RELATIONSHIP TO TANK OWNER °"] <br />- [:11. TANK OWNER ❑ 2. TANK OPERATOR <br />JJ— L 1 Lr^'�V-'�i'C-s I— LIC JZ3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ <br />5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (1212007) -1/2 www.unidecs.org <br />