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Jun 30 02 08s53a Elite4u Contractors Inc 20946163if 42 <br />UNWIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND <br />CERTIFICATION OF INSTALLATION/ MODIFICATION JtIN30200181 <br />(One fonn .. project)' <br />J04*, <br />VIR <br />' .:. L '. t tidtl .l 1 ,lN O TION . ; :._ "':T6.Tj�..: %lryq�r, <br />-ACILITY ID # (Agency Use Only) ;I <br />NAME ( 1v Name or DBA - <br />6 6•c� FiTI, nZ I +- <br />If. iNSTALLATION�/ MODIFICATION PRQJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that aaDlWORK AUTHORIZED UNDER PERMIT 4S3b. <br />❑ I. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT /� d ��` j /i r <br />❑ 5. OTHER 65 (� v j <br />DESCRIPTION OF WORK BEING CERTIFIED: 483a <br />Guns a m,',. --- <br />Vin. c4 cTOR moo. <br />� <br />/ MODIFICATION <br />CONTRACTOR LICENSE # 4szb. 482c <br />ICC CERTIFICATION # <br />U. tom : y/ G L� <br />N _CERTWICATION <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• <br />The underground storage tante, 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 />by a registered professional engineer having education and ex er�ience with underground storage tank system installations <br />SIGNATURE OF TANK OWNER OR OIXNFR'S AC.FNT I nn rc ara or,n .- <br />NAME (print) <br />WiFwa'S;TITLE: <br />NAME CERTIFIER'S EMPLOYER (DBA) 4 CERTIFIER'S RELATIONSHIP TO TANK OWNER 4' <br />t <br />j . � �—if, <br />t % <br />F-1 1. TANK OWNER ❑ 2. TANK OPERATOR <br />-}�(! t '94; CONTRACTOR ❑ 4. PROPERTY OWNER <br />(,- t/� f lX ( ( �` ((Y�( I'J' _ ❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 www.unidoes.org <br />