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Jan it 11 09: 46a Elitn V Contactors 12094 342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FORM J A N 11 2011 <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION 1 MODIFICATION <br /> (One form per project) <br /> ;. <br /> M0 <br /> FACILITY ID#(Agencv Use OntO °. <br /> 3. <br /> ------------ <br /> BUSIN NAME a P firy Name or DBA—Doing Business As) <br /> 104, <br /> J 3 � <br /> BUSINESS SITE ADDRESS IL gas• cI` �'('� c f. - <br /> G <br /> ST ,LL TIW...V)40D 'I <br /> cATtorr:ro <br /> 83b. <br /> a� WORK AUTHORIZED UNDER PERMIT <br /> TYPE OF PROJECT(Check ail that 4=1VJ (Number or Date): <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER ae3c <br /> DESCRIPTION OF V.'ORK BEING CERTIFIED: <br /> . .:...:.::::::... <br /> azx�;co..NTRAcTOR :T�o . <br /> NAME OF QQN kCTOIj PERFO A ER rNSTALLATIYN t MOD(`FIMT[ON 482a <br /> FLA <br /> CONTRACTOR ZICENS�E# `1 ; ICC CERTIFJQA <br /> N( <br /> , <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment 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 checklist 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 /> !?X a registered professional engineer having education and ex ence with and and storage tank system installations. <br /> BIG�NATURE OF TANK OWNER OR OWNER'S AGENT DATE 484- PHONE �� <br /> CERTIFIE VS NAME ate' C$RTIFIE S TITLE --- aes. <br /> / <br /> / AME/OF CERTIFIER' EMPOYER(DBA) ' �CERTIFIER'S RELATIONSHIP TO TANK OWNER ate' <br /> L <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> �' i !1�� ��l — ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-112 www.auidomorg <br />