Laserfiche WebLink
Apr 02 02 10:42a Elite Iv Contractors Inc 2094616342 p.3 <br /># 0 RECEI VEr <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />APR <br />UNDERGROUND STORAGE TAN -K 0 2 2008 <br />CERTIFICATION OF INSTALLATION 1 MODIFICATIOAM <br />(One form per project) J040ulr4 Cou(qTy <br />I. FACILITY INFORMATION LTH DEPARp6NA <br />FACILITY ID # (Agency Use On4) <br />BUSINESS NAME (Same as Facility Nwne or DBA - Doing Business As) 3. <br />Shlo <br />BUSIN9SS SITE ADDRESS 103. <br />CITY 104. <br />J;za q o7a P7 <br />11. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (ChecL-g&Lkqz agolti 433a <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />0 I. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />El 2. PIPING INSTALLATION OR REPLACEMENT <br />5C <br />rl 3. SUMP INSTALLATION OR REPLACEMENT <br />rl 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />3 <br />;R!5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 493c. <br />4ixN1 re-piaee4 Fiff 5p.11 + WL" Opta <br />q C) cc P <br />4e(a o, Cc-fr,'1iL— p,W-,—k <br />V, d �J Sp a I I b.L�J pwla-, 5'%c-Atc-i IvAk. fe&�- 4,r VK -kr. vwrc, ir <br />74C , <br />111. CONTRACTOR INFORMATION <br />NAME Or CONTRACTOR WHO PERFORMED INSTALLATION MODIFICATION 482a <br />ONTRACTOR LICENSE # 47 <br />CONTRACTORS <br />CC CERTIFICATION # 492. <br />LeCe C)O(Lp <br />a (4 L'�T <br />IV. CERTIFICATION <br />I certify that the information proAded herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in' 3 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 />,a registered professional en 'neer having education and ex erience with underground stoLage tanks tem installations. <br />SIGNA E TA 'OWNER OR OWNER'S AGENT <br />DATE 494. <br />PHONE 437. <br />1 635 7 <br />CERITFIER'S NAME (print) 495 <br />'VT-e-agj <br />CERTIFIER'S TITLE; 436, <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 408. <br />CERTIFIER'S RELATIONSHIP TO TANK 0ArNER 489, <br />�I ,M <br />IV <br />❑1. TANK OWNER ❑ 2. TANK OPERATOR <br />tlute <br />[J3,CONTRACTOR ❑ 4. PROPERTY OWNER <br />EK.'OTHER AUTHORIZED AGENT or TANK OWNER <br />UPCF UST -C Rev. (12/2007) -112 wwwxnidomorg <br />