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flug424 12 11z02a Elite IV Contactors 1209461634 p.1 <br />UNIFIED PROGRAM CONSOLIDATED FOR 1; <br />UNDERGROUND STORAGE TANK <br />CERTIFICA'T'ION OF INSTALLATION / MC DIFICA'PION ` <br />(One fat tines irnirn <br />WORK � I C HORIZED UNDER PERMIT <br />(NUrnbe-( Date): <br />F70-111My t1� i- - 3 ,1 arkrcz' _-... <br />l "z. L - <br />aim 6 ' `'.c /r��° ,Si1 p�� <br />I certify that the information provided herein is true, accurate, and that the following ce n :itions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and <br />• The underground storage tank, any primary piping, and any secondary containment - as 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 :h local agency, inspected and certified <br />re isteredProfessional en ' eer havin education and experience with underground ;G a tank system installations. <br />iIGNATURE 0 K OWIS 'S AGENT DATF 494. PHONE esu. <br />acl <br />IF1ER.'S RELATIONSHL'" ; TANK OWNER <br />TANK OWNER [ 2. TANK OPERATOR <br />CONTRACTOR [ 4. PROPERTY OWNER <br />OTHER AUTHORIZED. V ' NT OF TANK O WNER <br />UPCF UST -C - V2 <br />Rev. (17/2007) <br />