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Jun 11 10 07: 39a Elite TV Contactors 12094GIG342 p. 1 <br /> TWEMD PROGRAM CONSOLIDATED FORM Ulu <br /> �JA'DEI:GROOlV'I3 <br /> STORAGE [AI�IC `> <br /> �ormpexp;oect�.:._.,.:.: •, ::: _, °� <br /> pp <br /> ..na., •' ... w.t ... .—... _ .v... !P>3'#'. vartid lWA ,.M.IG'P""'. _ ryy� '" Y.n �\�y T', «.� <br /> FACR=ID'S(r4gency ac Only) w. <br /> $Us 'AUE x Fa iyir or Dart—DomgSus n=2r) <br /> 'BUSINESS nZADDP.FSS iv3 y ioa <br /> _ <br /> TYPE'OF PROPE{3:(Chackpllihaxmnh>). ° WORK1lUTC�ORIZEDUNS?ERPERIli <br /> ;' I:TANKW5TAI14x10NORREPLACF3.+IEN�: (SVwmberocDat�): <br /> (Q"?.PIPINGINSTATIiE.TION:ORRERLAC RJT ' <br /> 0'.3.'S.E&fP INSTAL.LATION.OR REPLACEMENT. <br /> EMENT. <br /> ®:4:T-MERDISPFNSW CONTAD4MMDMTALI.ATION ORREPL-AC0Mfr <br /> 3:O7FII m. <br /> . _ <br /> - <br /> _ - .�SCl2II�lOJ�LOF�i?ORI�Br'"LJG- D:---- --- — --- -- --_•--. .----�--•4��s- — <br /> �. <br /> NAME o CONTRACTOR WHO PERFORty M n.>>STALLAnON.,n�,�nl�cAZIQN. .40L. <br /> CONTRACTOR L1 t. °�°. ICC'.CERTlFICATION# <br /> I certify.that theiul'oirnuation,provided heretic is.trne,accivate,and that tlze.followiq;ciendit?oiQs.have been satisfied: <br /> The3ustalIerhas mert6e requia ecneuts set frnYl� 23 CCR§27IS�sstbdivision (g)aztd'{]z)= .: <br /> •;: The nndergrophd:storage.#ank, any PSS' Pte.ad aay, secondary. G°n tacas installed`according to applicable <br /> - voluntary cconseusus standards and auy�aoaznu#aatria er's written iaiiou instructions:.' :. <br /> wm*iistoct in*e mauu Facf►uer's-instaIFation`chccidisflias :compIpTtrd <br /> :. <br /> The.iustallatioa Isas.been inspected'and, rovede local-a n..;or�if . d'. the Io;ai �'ne3', and certified <br /> aPF hY cs recfuire h3' inspected <br /> b a resistcred` fessional.en a s. o edttcati�and exaerience rovith•vndecsround. taiatc'S.Men iastallafions, <br /> asa <br /> SIGNA OF TANK <br /> OWN R OR'OR�NER'S.AGENT s7. <br /> :.: DATE.': PHON& <br /> { <br /> r <br /> Is nes CFS ^_may aeu <br /> Y. <br /> OF CERTIF7Et2'S EMI'IAYER(ABA)' CIItT:lb7F1L .dLECATIONSHiP.TO,TAN 'OWNER AME <br /> ... ;. ..:.•.. ..: ... ... :.�::4. <br /> •TA�7KD�RT�41+I-ORERATOt.3E2:� <br /> txoPl :TYov�tlV2aQ� <br /> . .. <br /> • ;. <br /> TIiHR.:A.UMO RIZED AGENT OF TANK 6WNER' <br />