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Mar 20 02 09: 27a Elite Iv Contractors Inc 209461 "42 p. 2 JA <br /> IVIN <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agencv CIse /t1_o <br /> BUSINESS NAME(Same a ci ,,Vame at-DBA—Doin&Business As) 3. <br /> /d <br /> BUSINESS SITE ADDRESS 104. <br /> '13A� <br /> II_ INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that a0piv 483x. WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTIO O WORK BEI-JG CERTIFIED: J , 483c. <br /> 1 <br /> A� <br /> xv <br /> 1II. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTORA1W111H0 _J1F70D;gSTALLATION/ IFICATIONCONTRACTOR LICENSE 48zb. ICC CERTIFICATION# 482c. <br /> W. 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 a re 'ster rofessional engineer having education and experience with underground storage tanks stem installations. <br /> SIGNATURE OF . NK OWNER OR OWNER'S AGENT DATE 2tt�� a a84. PHONE as7. <br /> go <br /> CERTIFIER'S :AME rint 485. t a8r. <br /> CERTIF R S TITLE: <br /> NAMED ICER IFIER'S EMPLO " D A 488. <br /> CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> P ` + ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> ft-10— <br /> /13.CONTRACTOR [14.PROPERTY OWNER <br /> ( 25.OTHER AUTHORIZED AGEVT OF TANK OWNER <br /> UPC'UST-C Rev.(1212007)-1/2 mviv.unidocs.org <br />