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Jur*07 12 05: 28a Elite I V Contactors 12 094616342 p. 2 <br /> -UNIFIED PROG CONSOLIDATED F IRM ' <br /> UNDERGROUND STORAGE AX( <br /> CER CATION OF NST A.TION 1 A ic)DmCA.TTON' <br /> FACILITY w#(:tge„cy we only) `y <br /> EUSINESSNAME�e FaciifiyNavne�J / i Bur'e�reQs) a. <br /> BUSINESS s1T ADDRESS <br /> A)ncu ),V <br /> d <br /> F; <br /> TYPE OF PROIWT(Ck=kfigffiM, <br /> 0 L TANK INSTALLATIONDR REPLACEMENT: WORK �OR�D UNL)ER PERMU .. <br /> 0 Z PIPING INSTALLATION OR REPLACEMEAIT ;(Numb )r Date): <br /> ❑.3.SE9 P INSTALL 171ON OR REPLA:CEIwt MT :D'A.UPR3ER DLSd'EA?5ER CONTA IT INSTALLATION OR REPLA �.� <br /> .07HE•R <br /> DESCRIPTION OF WORKBEING CERTIFIED: — <br /> . r �•! - '. 483a <br /> { <br /> 1 6i 11''x' 1� �� - tc�! e✓ I' ( ► <br /> NAME OF CONrRAGTOR WI30 PERFORMED INSTALLATION 1 MODIFICATION . a $ <br /> 4M& <br /> CONTRACTOR LI SE# . dCC'CER IO . <br /> f <br /> Y uer#ify that the fn#ormation.provided herein is tone,accurate,and that the following c)e l(tions have been satisfied: . <br /> • The installer has met rhe rM'in=wffi set forth in 23 CCR§2715,subdivisians(g)and(z) <br /> • The undergrouad storage.tank, any primary,pi_pirill and anysecort <br /> dory cantairnriez)t, tas installed accaetfSng to applicable <br /> valuntazy.eonseasus and arty: teuer's written itestail$tion ins6ructions. <br /> • Al.woiric Bate:in the mauvfacfuree's'installation checklist has bye.completed.` <br /> • The installation has been inspected and approved by dee local. if <br /> ¢ tb local a <br /> rets by gent inspected and certified <br /> a rofesasiional ea Navin educatiaei and ex encs Witt,undetwound tank- <br /> instal Mons. <br /> SIGNATURE TANK.O OR OWNER'S AGENT - <br /> Mu DATB 4$4:. PHONE 4n. <br /> 10 <br /> CERT 'S NAMEgpt). 4as CER 'S TITLE 486. <br /> . � ;�:�..�' ������ � ���.:C_ ( . 9•jam:.: <br /> NAME CER 'S EMPL Ya(DBA) CERTIFIER°S REI ATIONSHU'.I )TANK-OWNER . <br /> MMM" <br /> T-Lan-&,e <br /> /� AIiiK CJ9JNER 2 Trii�iK OPER 4TOR <br /> 4t l� .�.C' J OONTRAGT©]2F. [ .4.PROPERTY OWNER. <br /> 5.aTIIBR AUTHORIZED!.'L :dT OF TANK OWNER <br /> w UiPCF UST-C Rk(Y2tIp87} <br /> www nxid9=Arg ? <br /> j <br />