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Jul 1'AL12 11 : 39a Elit IV Contactors 120946L&342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED t RM <br /> UNDERGROUND STORAGE TANK; <br /> CERTIFICATION OF INSTALL A nON/Y 0,DIFICA TION <br /> fOne£o .P .P ).... ..' . <br /> FACILITY ID#(Agency Use Only) {r <br /> BusrnlEss NAME ;_ _ - :. <br /> (SameatFQcilityNarneor138iI-DoingBusiacssAs) . . a. <br /> -ate b , •�• € <br /> ^ tf, n: <br /> BUSIlVESS SITE ADDPMSi Crry, <br /> .5•c .• � _ 'F>3 n���..'.�..'�b, .??x .si<r;.f:Ziee��.•vy+��;ey_.��.yy a�?.� <br /> : TYPE OF PROJECT(Chec,E all that annlvl asp° . WO1�K <br /> LUTHORIM UNDER PERMIT <br /> ® I.TANK NSTALLATION OR REPLACEM-N-T: (Nrc:ib •x Date): <br /> Q'2.PIPING INSTALLATION-OP,REPLACEwEN-r c_ <br /> F 3.SUNK'MISTALI.A.TTOIvT OR REPLAt:EMENT_. j / ' <br /> ©:S. DISPENSER CONTAINNIEWT INSTALLATION OR KEPI ACI NIENT.OTIMC : iC C Ls <br /> DESCRWT1oN.OF.WORK-BEING-cMRTIFIED:....._.__.._...—_. --.....:.....:_ <br /> iC✓� <br /> CAT,in Irl <br /> PC NA K <br /> l t c�{ sc :vit1 ` ,tj` <br /> Y61(: iC1tili. <br /> '�a , ..y.. ..A ? .. -,:%S f',a'' .'..4.i�m.�.C'NR'i� +�..��'i%4i•6�•rvM :. <br /> NA 6ffi OFINMCCL FvIJATION. <br /> to C6 <br /> CONTRACTOR LICENSE# t 4M. ICC'.CERTIFICATION4_ 4m <br /> 4:� G`ti�.r�lV TATE !�(`r <br /> J <br /> I <br /> I certify that the iaibrmationprovided herein is.trae,accurate,.and that the following a Iditions have been satisfied: , <br /> ®` T*imstaller:has-met the is set forth•.in 23 CCR§27151, <br /> subdivisions(g)and(1 , <br /> • The underground storage tank, any Ply pig,,and any secondary'containni:n ;ryas installed according to applicable <br /> ...voluntary'COnsensus-'s -and-any,manufaattuer'swritfen insWIation4wtiucdons. <br /> kll work,listed in the Iua6i fac6urer's-installation chemist bas been completed <br /> ea mm, been inspected and.droved-by the local agency,.or-ifracllrired by 1e local aagency,inspected and certified <br /> b a ie ' ft ssional e .havin education and erience With un ung �nra tank em-installations. <br /> $IGNATUR£OF TALI:OWNER'OR'OWNER'S AGENT DATE 494. FHONE �7- <br /> '' l` `GSC )fit- 37 <br /> CER-I`VlER'S N lzeaas. CERTTFlER'S.TITLE w aa5. <br /> , d <br /> mu\ OF T¢;IER'SENIl'LOYER(DBA)- ;\. C,. °88 CEB7IFTiIR'sRELATIONSIR -0..TANKOWNBR 4N.. <br /> l .�t t V, ('Til F t` C y 1.1ANK0W?VEit ,�•2�'ANIC"OPER;4TOR <br /> 3:CONTRACTOR .] 4.PROPERTY OWNER <br /> m : <br /> Q:5.O.TEIER A'UMOPMI): TIENT OF TANK OWNER <br /> x`'n 17217UST-CRev.(1=0n-VI wwwmnidemerg'. <br />