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Mbr 03 10 09: 38a Elite IV Contactors 12094616342 p. 2
<br /> UNMEED PROGRAM.CONSOLIDATED]FORM
<br /> UNDERGROUND STORAGE TANK
<br /> CERTIFICATION OF INSTALLATION/MODIFICATION
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<br /> FAL;LUTY LD1(.4oeney Use Only)
<br /> BUSINESS NAME
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<br /> BUSINESS.SrTE ADDRESS CITY toa
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<br /> TYPE OF PROJECT(Check ga j4Lam , 483x, WORK AUTHORIZED UNIMER PERMIT 'mob
<br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date):
<br /> ❑ 2 PIPING INSTALLATION OR REPLACEMENT
<br /> ❑ 3.St&W INSTALLATION OR REPLACEMENT C'{/�
<br /> 2-6
<br /> D 4.UNDER DISPENSER CONTAINt�T
<br /> INSTALLATION OR REPLACEMENT `✓i 1 j
<br /> 5.OTHER
<br /> DESCRIPTION OF WORK BEING.CaUMM: 4sx
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<br /> NAME OF CONTR CTOR WHO PERFORMED INSTALLATION/MODIFICATION 4sia x
<br /> COIVTRAcroR cic *rsE °�'' ICC CERITFICATION 4 40m
<br /> as
<br /> I certify that the information provided herein is true,accurate,and that the foIIowina.conditions have been satisfied:
<br /> ® The installerr has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h).
<br /> a The underground storage tank any PAY PiPInS, and anY secondary containment-was installed according to applicable
<br /> vohmtary consensus standards and any manufacturer's written mstalllatzan insiructions.
<br /> • All work listed in the manufacturer's installation checklist has been completed
<br /> • The installation lias.been inspected and approved by&e local agency,or if reT&ed by the local agency, inspected and certified
<br /> by a registmed professional.ea ' ear Ravin education and experience with underaromnd storage tank--installations,
<br /> SIGNA OFT. O R OWNER-S AGENT R '. DATE 4�. PHONE 4sr.
<br /> CERTIFIEI2•S L'AM>»(print) 4e5. CERTIFIER'S21TLEc. 486^
<br /> AFMDENZATI
<br /> NAME OF CERTIPIER'S EMPLOYM(DBA) . CERTTFfER'S'REI.ATIONS1W TO.TANX'OWNER 489.
<br /> EA14�,,. i " -0 I..TANK'OWNFdt ❑".2.TAMC OPERATOR
<br /> ❑.3.'CONTRACTOR ❑.4.PROPERTY OWNER
<br /> ❑ 5.6THER AUTHORI2:£D AGENT OF TANK.OWNER
<br /> UPCF UST-C Rev.a=087)-112 waves mtidocs or®
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