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Sep 14 11 12: 57p Elito IV Contactors 12094 342 p. 2 <br /> UN,'MED PROGRAM CONSOLIDATE) -ORM <br /> [Jl IDERCROUND STORAGE TA.pj7 <br /> CERT]TICATICDN OF INSTALLATION! IODMCATZ®N <br /> . _.(One•forrnperproject);___.. <br /> I'ACILTfY.ID# .4 ra Use On1JI_. :.. � ,...,, _...: .: ,�• � �c t• w� '�� v � s�, .:... <br /> ' 1 <br /> BtISIIJESS NAME ry, <br /> (Same as Fn ill Na+ue a•DB.4—Doirsg Butinesr hr) - <br /> BUSINESS-Srm ADDRESS ».: .CITY <br /> T-H :`t <br /> pg— <br /> N • <br /> � v <br /> 4: <br /> •T17'E OF PROJECT(Che,:1•aTl rh�r�„nh,� as3a "1� ,sates_,w•s <br /> 0,1-TANK LVSTALLATION OR REPLAaMEN i WOl tk a.UT:iORIZED UNDER PERMIT. astt.� <br /> [�2.?PING TNSTALI;ATION OR'REPLAC•EMENT' (Nmol r or Date): <br /> p 3.SUMP WSTALtATTON OR REPLACEMENT <br /> D 4.UiJDERDLSPEhTSER CONTAINMENTTATSTTALLATION ORBEPLACEIvIENT <br /> 5_,0171ER <br /> DESQttYT7UN OP WORKBEING 4IERTII7k : <br /> TREY t(J Yl`J�S Tom'7— <br /> Skit,- C.q`to' tl ZU �C.I'alF�t 1x ;i ' IOC�+S�SI <br /> X 5 5 Wg7k)-ubT b i <br /> l�RYll;IA Q, u�ST ��ST �T 5.cormvw� , ; CxC,I- flu <br /> t! r� <br /> t..i� _ <br /> Cs�CI(X1Cred U� C5 -ti T 'l4. P�' 5 um5 <br /> PCTmu 1$ czt X11 p���ert�c� fi ► t O, rt be dor ; <br /> ?AAlE OF COW-n; <br /> J uor� v�u► tNTRACTOR WHO PERFORMON/MODIFICAON <br /> aszL <br /> CONTRACTOR <br /> � iCC'CERTTFICAT70Nf� <br /> 1�� asp <br /> y� <br /> I Certify.that the information provided herein 1s true,accurate,and that the followxug crn ai ISaas have been satisfied: <br /> • The installer has met the reguiminents set forth in 23 CCR.§27IS,subdivisions(g)and(h.. <br /> • The underground storabe tank any pruilary piping, and an sewn <br /> volun Y dory contaimnent u installed according to applicable. <br /> tatty:consensus standards and any manufacturer's written installation instructi ons. <br /> • All work listed is the manufacturer's iustallation.chectdist has been completed <br /> The installation has been.inspected and approved by the Iocal agency,or if required by fir <br /> a 'stered mfessional sn.ineer hay% a ;cal agency,inspected and certified <br /> m�educationand a erience with and ound star l;e tarik <br /> SIGNA TAN"WNEB pppR O 'S AGENT <br /> r <br /> DATE r a.. PEIONE, 497. <br /> r / �•` `� 13 -2x`11 (2.� > � ., <br /> T 'S NAME(print) aes. - <br /> CER7TCrt:53TTC E : 486 <br /> NAME-OF CERTDMME S EWLA'YER <br /> (DBA) ase. <br /> ' TIF1ER'SRELATIONSIBP.IO ;'.NLZ'OVi'NER <br /> 489— <br /> '01 -rANK!0VRQR- <br /> ee..01:.TANK'OVRQ2: [J 7,ANy--pPERl4TOR <br /> E:, <br /> cl PROPERT]'OW24ER: <br /> -❑ 5.OTBER AUTHORPLED A'G.?2 f OF TANK OWAlER <br /> UPCF UST-C Rev.(1212007-112 www.m�idoezor <br />