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Nov 06 08 12:16p Elite Iv Contractors Inc 20946I6342 <br />NOV 0 7 2008 UNIFIED PROGRAM CONSOLI'nATED FORM <br />UNDERGROUND STORAGIE TANK <br />SAN J0A1QUN4;&W1F1CATTON OF INSTALLATION A MODIFICATION <br />ENVIRONMENTAL (One form, per project) <br />TY iNFORATION <br />FACILITY —U <br />ttUSLNESS <br />or 0M — Doink, BVrinew <br />WJbINENS blK ADDRESS CITY <br />At <br />11 INSTALLATION/ MORTFICATTON:01 <br />TYPE OF)'ROJECT (CIJLck fill - <br />,k�� 48 <br />0 1. TANK INSTALLATION OR RFMACE&M-IN7 <br />0 2. PIPING rNSTALLATION OR REPLACEMENT <br />0 3. SUMP INSTALLATION OI(REPLACLMENT <br />4. UNDER DISPENSER CONTA1NMWfINSTALLATION OR REPLACEMENTR 5. OTHrut <br />8 <br />�MEPINSTALLATION/MODIFICA:rioN <br />FECT DESCkiPTIO'N <br />�W6)m AUTHORIMD UNDER PERMIT <br />(Number or Date). - <br />--1 <br />C'TRA ebR LICENSE # ICC CER <br />f certify that the information provided herein is true, accurate, and that the following conditions have been satist-led: <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 contuinmcnt 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 check -list 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 profinsional engineer hj!iM education and cxperioncc with under round storage tanks stent installations. <br />SIGNATURE —TANK OWNER OR OWNEWS AGENT DATE PHONE <br />CERTF)FIERt NAME (print) rint) coa <br />I Itf <br />O 40 A - -- <br />F '512 "LOYER(PDBA) RULATIONSUIP TO TANK OWNER 499. <br />L TIO' <br />0 2. TANK opr.RAToR <br />-0 <br />0 IT - rOR 0 4. PROPERTY OWNER <br />0 3. CO 'LAC W -,7 OF TANK OWNER <br />0 5. OT7 <br />LR AUT110,UZED AG r <br />LIPCIP LIST -C Rev. (12r-eu7) 1/2 www.0111demorg <br />