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Feb 08 11 10: 34a Elite IV Contactors 120946 6342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MOR Dj ICATION' a � t - <br /> (Onefonn er t) <br /> 777-777-77 . <br /> a <br /> 7777 <br /> I: FACILITY INFORvIATXON- <br /> FACILITY ID#(Agency Use OW}) <br /> BUSINESS NA E FAC N rDDA Doings.9h s) ' <br /> 104. <br /> Le <br /> BUS TESS ITE ADDRESS ITY <br /> 1 <br /> .1�.:INSTALLA.'1IOv/M(Tbi�'ICATION PR( JEGT]?ES�;I <br /> 483b <br /> " --' 4s3- WORK AIT 1)RIZED UNDER PERMIT <br /> TYPE OF PROJECT(Check all that aonly) (Number cr ate): •--r <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT, <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT _ �1) r } F�f <br /> ❑ 4. ER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT ! 1 Ci <br /> OTHER _ 1 463e <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> R <br /> I <br /> II. CONTRACTOR:INFE}RM-aTION <br /> NAME 0 R PIN�STALLATION/MODIFICATION <br /> •� � i �(iJ — - 46zc. <br /> 46zb. 1 ` �fflr <br /> / <br /> CO k �SE# <br /> 777 7.,. .;`......'ir::• <br /> ry e�RTIFIcaTio <br /> .... . :.. > . <br /> I certify that the information provided herein is true,accurate,and that the following-x 1 ditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and.(L . <br /> • The underground storage tank, any primary piping, and any secondary containm•:n was instalted 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 ins lation has been inspected and approved by the local agency,or if required by lte local agency, inspected and certified <br /> b a re i Bred rofessional engineer having education and ex erience with under ourld a:ora84 taPH�N em instaltatians. �7 <br /> 81G�'ATURE 0 TAZJK OWNER OR OWNER'S AGENT 4DATE ER'S TITLE: <br /> CtERjIPIER'S Ait:ME(primo /7777.. <br /> QAY <br /> "- _!o -.fi✓i.'c.-.—✓ C/�G'�"U��' 488 489. <br /> N' OF ERTIPIER'S E OYER(DBA) CERTIFIER'S RELATION!;j I'TO TANK OWNER <br /> ,i ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> \/f �l � � �Ct•' Z� ❑ 5.OTHER AUTHORIZE: .',,GENT OF TANK OWNER <br /> Rev.(12P-007) <br /> UPCF UST-C-12 <br />