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Dec 21 12 12: 02p Elite IV Contactors 1209461,6342 p. 2 <br /> UNDERGROUND STORAGE TANK <br /> CERT CATION OF INSTALLATION/'T CODIFICATION <br /> i (One form perprojmt) <br /> FACILITX ID (Agency Use Only) <br /> �....:• <br /> $U`S��"S�'A�(S:weasFAC7LTtYNAME.�D&1—AangB,ainessAs) <br /> 9, <br /> BU..- S SITE ADDRESS <br /> 103. <br /> CITY <br /> �/ alfa .r. , } �t� l.d[ I�' " �` "i �;• loa: <br /> i <br /> TYPE of Pxo.IEeI`(Cf-akaAg W <br /> 0 '-TANK INSTALLATION OR REPLACEMENT" 4s3a WOIi K .:TTHORIZED UNDER PERMIT 4 36. <br /> ❑.ZPtPIIJGBISTAILATIOKORREPLACEIvIEN'I' (NW4 .)r Daft)- <br /> Q-:3,SUMP INSTALLATION OR"REPLACEMBN'T <br /> Q 4:I)I1bIwR bISp 1 Psok TAN ERT'INSTAL OR REPLA CEMENT <br /> CC P <br /> 5.OTTIER <br /> DESCRR'TION OF WORK BEING CERTIFIED _ <br /> r;���'�;• <br /> NAME OF C01V TRACTpIt WHO FERFORtvIEp INSTALLATION/MODIFICATTOx <br /> CONTRACTOR LICENSE41 <br /> ` '` _ <br /> +aze. Icc mTIFICAITON# <br /> dj <br /> f 2. <br /> Ce _ .._... . <br /> rfafy-Nhat-lheautormatian•• ruvided-herein is-�r-ea -accura <br /> tom;attd Shat thte follatvfugco�at tions-have-been-satisfied: <br /> • 7Che installer has met.the requirerneuis.set forth iu,23-CCR§2715;subdivisions - - <br /> • Tlie ands rag tank, anY. 1 i.i <br /> ��) d(h;. <br /> rground sto _ e <br /> vo untary consensus Stan an an 'p P ".and any secondary cantaiprrrent K s installed accordin to applicable <br /> Y ctu, s wxatten on nrstrnctrons. ` _ g <br /> • All.work listed in the manufacturer's installation checklist has been completed. i <br /> • . TSI installation has.been ins <br /> b r istered petted and approved by the Local agency,or if,required by the ocal <br /> SI fessronal,en ' ser Navin education and a encs agency,inspected and certii'red <br /> _.®]F T,gNK.. ,R+NER OROWNER s AGEI7T with under ound star ;.e tank stem insta <br /> DA E dations. ; <br /> j_t <br /> fER'S TITLE. axa. <br /> CERTTF <br /> NAMEoI iEkIs i©max(baAa. . <br /> i <br /> y �� CERT1FIi[z's'xET AT[oIVSI :x o ,iI X OWNER— nes: <br /> i1T .1 T..•e� < •Q I.TANKO <br /> -3.f t�c WNL E i. VAMC OPERATOR <br /> Q 3.CONTRACTM ['. :;'ItOP <br /> - ERTY OWxEIt <br /> Q S.OTfTi_AUTTORTLEDACx3I 'JETANK.OWNER.,c-1/2 <br /> _I!2 <br /> Rev.O 2007j <br /> i <br />