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Oct 26 08 03: 05p Elit,— Iv Contractors Inc 209461U42 P. 1 <br /> A&& <br /> 4p <br /> LINI FIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One lorm per project) <br /> I. FACILITY INFORMATION <br /> I-ACILI'l Y 10 9(Agrencl-Lye OWY) <br /> BLISINLSS NAML Game as FacilitvAlame or DBA - Doing Business As) <br /> �cench Can MG bcwak �Aaukl\ <br /> 1 1" I CITY <br /> Tb= <br /> .............. <br /> 11. INSTALLATION MODIFICATION PROJECT DESCRIPTION <br /> El I.TANK INSTALLATION Olt REPLACE'MF'NT (N Limber or Date): <br /> 02.11111INU INSTALLATION OR 1UPLA(TMENT -C:� <br /> C3 .1 �5�a" <br /> —Y-IMP(NISTALLATION OR RITLACIrMENT <br /> 0 11.U N Dkit 1)PS I'LN S I':It CON FAI NIVILINT I NS1 ALLA NON Olt REITACUMENT <br /> El 5.OT 1-11{It <br /> DESCRIIITION­6,'WORK MAN(;t1TWI'lViFi): <br /> cjoc)0 &C,5d rut'l b� O C06 mo <br /> 6 be T\ -Icleb- 6�V-1 F�ll <br /> RELIL Ls '61—ii <br /> OCT 2 7 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ......................................... ............ .......... .......... <br /> 111. CONTRACTOR INFORMATION <br /> NAML OI:CO NTR ACTO It W I10 ITH FQ K M 11;0 IN'-%I AL LA I]ON i MOD 1­P�FCX��,ION <br /> LUL UE Y&W(15 l 2"' WULtO Df. aff-M-0 Cn952-a✓ <br /> ) <br /> CONTRAC7FOR l.K'l"N.,F;f ICC C171t-I'lQ CATIONP <br /> ................................... .............. <br /> IV. CERTIFICATION <br /> I certify that(lie im-4)rmation provided herein is true,accurate,and that the following con(litinfis have. been satisfied: <br /> • The installer has met the requirements set 6orth in 23 CCR§2715,subdivisions(g)and(11). <br /> • The underground storage tank, any primary i.)ipiiig, and any secondary containment was installed accurding lu applicable <br /> voluntary conscriRLS standards anclany mantiffichirer's written inslallaliun i ristnicti oils. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The illitilkitioll has been inspected and approved by the loenl -i,oency,or if required by the local ng icy, inspected,incl cortifiled <br /> by a registered proli:s i9nal engineer having cd tion and cxlll 'rieflco With lank sy;tem instntlatitws, <br /> SIONATLmkoi, DATIi 44. PIIONI; 47 <br /> 26q 00 <br /> CERT11:10Y5 NAML(print) <br /> NAME Ol'CERTIFIER'S F.MPLOYF.Ii(I)IiA) CL10,11-JEWS RLLATIONSHIP TO TANK OWNHZ <br /> r_j 1.TANK OWNF'.1c ❑ 2. 1 ANK 0111,1RATOR <br /> 'JEQ,CON')KA0 OR ❑ J.IIROIII;lt-1-Y OWNER <br /> ❑ 5.OTi-ir.lk AUTI-101WIT11)AGENTOI,' I'ANK OWNFR <br /> 144vv,(I Z124107)-1/2 <br />