Laserfiche WebLink
Mar 19 09 10: 44a Elite Iv Contractors Inc 209461 42 p. 1 <br /> C3 e <br /> UNT.FEED PROGRAM CONSOLIDATED F<)R. I `¢ <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION!MODIFICATION 2009 <br /> (One foram per project) SAN JpA <br /> L.,FACEUTY INFO T 16 <br /> FActury rn.n(rtgcnzv uta onl,J ` <br /> 13LS,1'NL•;SS N Py(Same as 1'"acilitylame a-D Doing firrssirness.9.$) s <br /> BUSINESS 517x:.Al)WL'y' �a�• C L1 y ,®4. <br /> rr, �rrsr ,r,AT16N i MobdliCkFYONPRCi E&nEscku>?ezoN . <br /> TYPL OF PROTECT(Checka!I firer ornfvl a 41111. WORT:AUTIiORIZED UNDER n—R MIT <br /> ❑ 1.TANK I:NS 1'ALLATION OR XL-PLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION ort RC PLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR RF11.ACEMENT <br /> 114.UNDER DISPENSER CONTAINMENT JNSTALLATiON OR RI:PLACLML:NT <br /> ❑ 5.OT14ER <br /> DF_SCRU ION OF WORK BEANG CERTIPMD: 4t Vic. <br /> 1 <br /> 0 ��[,�,�aL �; ��(%�Q� U to ! - , � f V3�a- <br /> -A0 q <br /> I.;CO3NTRACTOR INF® 7'ZU�® . <br /> 4 <br /> NADNIliUt' T U 1lURMR 5I" TION! UI'DD'1CATIUN ! :n <br /> r <br /> coN ci'c}dr,ICGNSL� f- 4�b' ICCC1i1L'rLI�ICA <br /> IV.' CERT'iFllt ION <br /> I certify that the information provided herein is true,accurate,and that the following conditions leave been satisfied: <br /> • !lye installer has MCI the rcquirements sct forth in 23 CCR§2715,subdivisions(g)and(h). <br /> + The undcrIgound storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any nlauuiactu er's written installation instructions. <br /> • AlI work Iisted in the manufacturer's installation checklist has keen completed. <br /> • The installation has been inspected and approved by the local r gcmyy,or if required by UIC JocaI u;;eticy, inspected and certified <br /> b rc-stored prorcssional engineer having education and experience with_undcrground stomize tank syystem installations. <br /> 7GNA RE OF TANK OWNER OR OWNER'S AGENT OATS 4x4• 1 PFIC)NL 4x7. <br /> 1.7 <br /> c' irtu'S NA <br /> ME(Fraud 4s�' c T I l:k.'S TITLE: <br /> (i�i ��_ ;(�tom✓ <br /> NAML OF C'EK ER'S 1?MPL.O ) qsx CFR.T IFIER'S RELATIONSHIP TO TANK OWNER 460. <br /> TE <br /> (Ifi6PA6� <br /> ❑. 1.TANK OWN r?R ❑ '..'LANK OPERATOR <br /> M 3,CONTRACTOR El 4.PROPERTY OWNER <br /> ® 5.OTHER AIITHOltt%1 1)AC,Fn r OF TANK OWNER <br /> U F 11-ST-C Rev,(12!2007)-112 www.unidoes.org <br />