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Nov 12 11 01:09p Elite IV Contactors 12094G1G342 p.2 <br />UINIF ED'PROG� C®NTJ®AJH A J L fJ iy� <br />LTNI3I RGROtTND STOR.A,GE T.hINY, <br />cFRTIFICATION OF INSTALLATION W <br />EOneform:grrproect�.:.._ <br />.. x;�� ' �.ktx`9+•- tX^�'a�'+Tx. R ii e•`a'a^� �i 3 <br />FACILITY ID # (Rg=V Use ot:ty)IL <br />BUSINHSSNAME CSme CS Aa- <br />tuA <br />or DBA—DoingBusvretr 4x) <br />to3, <br />BL'SU SSITEADDRESS <br />337- } <br />'1�" :.. rte` S'ss. •Ei "tR4�ATe R 3N1PS`!!' -x' i`'�� a � ��'" <br />TYPE OF PROJECT (Cieeekull that aonlvl (Nu ni <br />Q .1. TANK I NSTALLATION OR REPJU�CEI� . <br />.F1 2..PIPING INSTALLATION ORREPL.AC:ENEENT. <br />M. 3. SL14P INSTALLAi70N OR REPLAC0'r _ <br />4: UNDER DISPENSER, CONTAINMENT INST° LLATION OR REPL 4Cf Tr' . <br />--• •-- _ _ ...— ._DESCRFJ'TIONrn <br />-OF_��.ORF.�EIIJG- . <br />F <br />i <br />NAI M OF tv cT R VMO PERF0 INSTALLATION. <br />4S'!b. ICC�CER QI', <br />CO CT'OR LICENSE # <br />x a ,o <br />' .�k5 .`�� ^� •='ax+t �1�i-..w'iE �S�.Y.j?�d'�y� '� q �, r nE �"9;,$�n '�; <br />t��Jr1 �� :X� 1':,.1� �tk�tN d'a .. . v..w , *.Ah 4:.. ,..E.'iY,. ."x Wkz w.,-},.. •�+: <br />Icertify Oat the ziif& ormabioa provided herein is.ti ae, accilrate, gad that tiie fnllowix g <br />The snstaller has met fixe requirements set Earth iu 23 GGR'§2715; subdivisions (g) and <br />®: The undergmutld storage..'.any prima?' ,PxP and:any. secondary contain n' <br />- - nd a aty,manufacturer'S wntten'in <br />voluntary consensils standards stallatiouinstluctioz� <br />:. <br />All work listed in the manufacturer's •iustaIladon citecIdisf has beencolnPleted <br />The.iusiallation.has.i>ren.inspected and..approved:i the Iacal.a oncy, or ifrequirer. t <br />b a:te stered rofesssionaI.eupneer.havm-, education and e eneuce with' umderero n <br />SIGN TiJP.E OF TANK OR'NER OR O4INER'S AGENT_771�W/ <br />DATE <br />- <br />FAIT <br />emin ANT <br />� '?`t <br />° `"'�L^�q„ate „Rs Vii:.. T � w: t• - � "”` { � <br />xi <br />Li 3. <br />/ Let t r <br />--..-- <br />t y 1 d Y <br />� <br />-4E3h. . <br />A LrrHORiZM UNDERPERJWT <br />r or Date): <br />.. <br />_ <br />.....__._.._._...:'....-...._.53;x. _, <br />t <br />�+a,t"��t..�•C, . ��t-.. a. q �ti-�� 1 i1+7f?'tu ' � 7�'•t i� <br />4m <br />482. <br />si>ditioins have been satisfied: . <br />li -w•as installed according to aPPiicable <br />the Iocal agenc5r, inspected and certified <br />i storage =I— system -installations. <br />484- <br />,PHONE . asz <br />1`�3: <br />