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Dec 30 08 10:26a Elite Iv Contractors Inc 2084616342 P.1 <br />UMIFIX D PROGRAM CONSOLIDATED )FORM <br />UNDERGRO11ND STORAGE TANK <br />A <br />CERTIFICATION OF INSTALLATION / MODIREC112MM <br />(One form. per projcct) <br />El <br />FACTLIT'y LD # (Agency Use Ontj,) <br />(SameLIUSiNESS 01 ry Name eir()LU - Dvihj- Rusin = AN) <br />SAN JOAQUIN COUNTY <br />l <br />h <br />ENVIRONMENTAL <br />LAUIL5SINES Sl n,; D c17'y - ­ I I -MrAH I MENT —Ria7 <br />h, <br />YY. INS�ALLAION%h�OAi'YCATIi® T D ESCRUPTION- <br />TYPE OF PROJM_`T (Cimek J.L&qLjg10 W014KAUT14ORIZEDUNDF_)RI,L.,RMIT 45 r- <br />0 1. TANK INSTALLATION OR 14MILACEMENT (Number errMtt;): <br />❑ 2. PIPING INSTALATION OR REPLACEMENT <br />3. SUMP NSTALLLATION OR RMACMENT <br />❑ 4. UNDER DISPENSLN CONTArNK41NT INSTALLATION OR RE)II-ACEME <br />i, OTHER M�R <br />IPTION Of! WORK)j M -G crwriyum: 3,. <br />48. <br />It <br />4-ke. <br />j&( <br />L <br />,L&k,) L4k, 0-AJU(VOrl­, <br />A L <br />L) Rylq <br />D <br />P <br />1, 6 ;.t, /_-?& / 0-0c.( <br />yt, <br />7d 1,1 <br />C /a <br />o kD <br />CONfACORWbwM - <br />N R VOIG► PERFAkMEL)!N.%TALL,,;rION /, MOL)WICATION 4X24, <br />C,VNTKACrOR LI E#. ICC CE-WrIFICATION It 48ZL. <br />CERTM. gATt <br />N <br />I certify that the information provideil herein is true, accurate, and that the following conditions have Ix -en satisfied - <br />0 Thr installer has met the requirements set fom in 23 CCR §2715, subdivisions (g) and (h). <br />• The undcrground storage turnk, any primary, piping, and any secondary containmcnt-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 chcck-1 i. -;t 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 eegi,;tcrcd profcssional en cer having education and e�-cnce with under round ;(�Eaamp y tank -system installations.SIUNATURE OrIANK OWNER OR OWNER'S AGLNT <br />axr <br />NAME OF CERTIFII:R'S FMPLOYER (DDA) <br />CERTIFIER -S RELATIONSHIP TO TANK OWNIM <br />El L TANK OWNER iANKoPr,%AToR <br />MVI cowntACTOR 0 4. moprRry OWNER <br />5.01-H R AUTHORIZED AGENT Or TANK DWNj rR <br />UPCF UST -C Rev. Mngn - V2. W%vw.nWdtK-_am <br />