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Dec 13 13 12:28p Elite IV Contactors 12094 1 -- p. <br />6. e® <br />U?MUD PROGRAM CONSOLIDATED PO 7M 7 <br />UNDERGROUND STORAGE TAA <br />CER CATION OF INSTALLATION % hi MY04WAr <br />itJne form,parPrpj)....:.:... ,HEALTH DEPARTMENT <br />S 0 •� <br />FACILITY 0 4 (Agowy Use Only) 4. <br />BUSINESS NAA9E (Same as FadliryName or DBA -Doing Busi less As) 3. <br />BUSINEss`SITE ADDRESS CITY los. <br />09 l J1� <br />°tS s <br />R <br />TYPE OF PROJECT (CherkaAaiw maniv3 483e WOP.K-UTKORIZED UNDER PERMIT 483b. <br />p I.'TANK INSTALLATION OR REPLACEMENT. (Npn x Date): <br />© 2.. PIPING INSTAMATION OR REPLACEMENT. <br />❑ 3. SUMP INSTALLATION OR REPLAMIEW. �. � i � �I Jt✓ r <br />0 4. UNDER DISPENSER CONTAINMENT INSTALT.ATION OR REPLACEMENT <br />5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: — 493c. <br />all LA <br />; <br />IK:t�S11�c��e�X <br />w ..v�`yy• <br />NBC,�4t ALF" <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 4MI <br />CONTRACTORUCENSE#:/� ��t S(., j�t2 �A t3�a821b' ICC'CERTIFICATION�i� 4 <br />l 3. . ! 5? ter{.+ l' d <br />I certify that the information, provided herein is true, accurate, and that the follows is c indibons have been satisfied: <br />a, The installer has met the mquirements set forth in 23 CCR §2715; subdivisions {gj an <br />The underground storage _tank; any. primes piping, and any secondary containv e:: was: installed according to applicable <br />Voluntary consensus standards and any manufacturer's written installation •. •on:. <br />All work listed in the manufacturer's installation cheeldist has been completed. <br />.: The installationhas been inspect6d and approved by the local agency; or if r q&ed the Iocal agency, inspected and certified <br />by a iegistered EMfessional en eer having education and experience withnu_oi Stora a tank stem•installations. <br />SIGNA F T O R WNER S AGENT DAT <br />_ PHONE <br />(/ 1 <br />CERT 487. 12- <br />SNN (pi6) ass. . CERTIFIER:S.TTILE: y—r. _ asp <br />NAME OF CERTIPIER'S EMPLOYER (DBA)-4U. CERTIFIER'S PELATION 31 'P TO TANK'OWNER <br />�s j( <br />C;2TANKOPERATOR.KOWNER <br />`CONTRACTOR 4..PROPERTY OWNER <br />OTHERAUTHORIZEI <br />AGENT OF TANK OWNER <br />UPCF UST-C Rev.212 = In " www.umed=A <br />(I 4a7} sg <br />