|
Jul 25 11 07: 29a Elite Tit Contactors 12094616342 p. 2
<br /> -UNIFIED PROGRAM.CONSOLIDATED
<br /> UNDERGROUND STORAGE TAN]
<br /> CERT CATION OF INSTALLATION/A
<br /> ' T 'FEICF,h' "ww... ... .. .,. ,.. ._. '.-..a ;yGa �"�,;,.....1,4nd',^�'s•�:.;+nrL'�ktMM1tfd''ik?"' - � - �ll ^mrt;�; _ _
<br /> �� •.-meq'" ,�.
<br /> • _:,. max:, r '� �F+;#*; � �:����'��" �.�v, '�
<br /> ..v*;?:".�`�'�'F7e��;�'`�Y �,,M;� 'a' `t "��."'••"'b��-'*�� -.s,'�'a��*S>"�,r. x�.� � �.r� .:-�:...�._ ,�Tirokr'6':�i
<br /> FACILITY ID#(Agency Use Only)
<br /> (;t '"'
<br /> SUSINESSNAME(SmneasFacifiryName or DBA-Doing B=ne=As) .€"P NT 3
<br /> BUSINESS-SM ADDRESS 103• CITY X04.
<br /> Wail 2,1k k
<br /> -.b --„ak`m+'>'aarsiu =:ct.* A.._�•cr:•�, .vr.!mz ra, ^_"ca r-s_..aY i�zi�e±?;.,:r=i?'tz';=.3's:s.:evv'.T;. :':v: -'a'''','_,:;xrc:e'r.::., _
<br /> ��� T� �y (�� y�'+► ,!^I tt ��tiY{{ce •��i.: }azo .'x5;:n.:•',';:'¢�:<i.'�»S:r+"..;''.
<br /> .r... yma ..>a�,... �,5.�--:'%:xs .�."v ' �^x : 6:. `3L"n" '�: y s. a7.>• •�'q�'cYf•.,i.�4:._..1:�.:..,_..
<br /> �,, . .� .u...n. �`^�'+ � '-' 'P' .i'1_Y.1:'ki� �.111'��.3� ' �ti+' �l'�5:..+F:riIC�4iH`. � ":;�I.�.M1.S'•'X'a.y xtr'x5*._. e-
<br /> ..0
<br /> ., r �;n. r xL-?.:: .+� ,.:. .�<t, .n...:.;Y.:....- r.a::_w :.:r a'�:_..:_,....>a=,.0 - - "rT! _^.am._ 4.'#^• :r+ -
<br /> TYPE OF PROJECT(Check all that atmlvl 483x. WOR AUTHORIZED UNDER PERMIT 463b.
<br /> ❑ I.TANK INSTALLATION OR REPLACE)VIENT (Nm tr or Date):
<br /> 0 2 PIPING INSTALLA77ON OR REPLACEMENT
<br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT
<br /> 0.4,UNDER DTSPENSER CoNTAINMENT INSTAId.ATION OR REPLACEMENT
<br /> _
<br /> S,OTHER - 11 .t ,
<br /> DESCRIMON OF WORK BEING CERTIFIED: 483-
<br /> l Cd eS tPwRe-CK tiff .-%c) W VMtz
<br /> C6iA�;s _
<br /> • I 4 • l V„ • \\i pk�
<br /> AFT"_ %t1G :i-f••. PaS
<br /> S -
<br /> k S: %
<br /> .ka,.•�Y. ?'S �_' w•:� ,R_ A. ?Fiwawe ).:-:A'.`.%A K:'Ai�"i.WW:£t .�"'A5�'?nh:,.-`:!.`X�n'i S4 Y'• j+aeS
<br /> IME .i '' ��,• a e€+sA
<br /> 31FSerc:mea,aa:wn;� ,c:xxa za:_evr",<x�r•r vs<^s'.f. � •x�.`.I ''ir., „e''i tz EM_ :rl.. ; 8
<br /> CTOR WHO PERFORMED INSTALLATIONlMODIFICATIQN Wu x Y:n,:,J::,,we:.x4s�
<br /> NAME OF CONTRA ,
<br /> CONTRACTOR LICENSE# 4M — ^
<br /> CC�CERTIFI TIO tra
<br /> �,"��, '8u(.3�,._.
<br /> r_T y.,., tl r w>, N
<br /> tU41 1rCPr.AU14a
<br /> _
<br /> m. .: .. .. a.. r".
<br /> ..r. ,J� •. ''. '!,- as i r {,l,.� a .YFs",� M.n:Wi" �Y".�.. 'W�.'�"-, A�',�_�-''ry,stli
<br /> I certify that the inforjnation provided herein is true,acenrate,and that the followin;; nxaditions have been satisfied:
<br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and j;i.
<br /> • The underground storage task, any primary piping, and any secondary containnte t %as installed according to applicable
<br /> valuntary consensus standards and any manufacturer's written installation instruction 4
<br /> • All work listed in the manufacturer's installation checklist has been completed.
<br /> • The installation has been inspected and approved by the Iocal agency,or if required i,t the local agency,inspected and certified
<br /> by a'ze 'steredprofessional en ' eer havinR education and a ence with underarou a( s fora a O O
<br /> TORE OF TAtank steem'installations.
<br /> 5I NK 'IJER R OWNER'S AGMI,'T DATE 484.
<br /> PHONE 487,
<br /> l_�33-1
<br /> TIFIER'S AT tP t) 485. (��)CERT9MR'♦S�T.ITLE: — 486.
<br /> _ OF CER s E�NFFL OYER(DSA) 4x8 CERTIFIER'S REI.ATION;:x 'To TANK OWNER
<br /> � - 1�? 9 489.
<br /> .�`3��s .�•�:1\ a-� ; ❑ 2.T�tZ�IK OVi'NER :[]Z TANK-OPERATOR
<br /> ❑ 3-CONIR.ACIOR I—] 4.PROPERTY OWIXER
<br /> OTHER AUTHORM D s GENT OF TANK OWNER
<br /> UPCF UST-C Rev.W_w7)-1/2 +vwev anidocs org
<br />
|