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Dec 04 08 03: 57p Elite Iv Contractors Inc 20946113342 P. 1 <br /> es <br /> U N I H ED PROCRAM CONSOLIDATED FORM DEC0 5 2008 <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICAnON OF!INSTALLATION/ M0D(FJCATKW, <br /> (One form per project) QMN COUNTY <br /> ENVip,C), <br /> r1plUEPA <br /> L FACILITY INFORMATION .,RTMENT <br /> rA0LITY ID#(Agency Use On(v) I. <br /> BUSINE-S'S NAME(Same w hircilftp Name or!_)RA <br /> V M(l _UO3 LoLd <br /> "USIN1`!S'5 ME ADDRI,-'ss CITY <br /> x (D� <br /> M. INSTALLATION/..MODIFICATION PROJECT DkS'CRIPTION <br /> TYPE 01' <br /> WORK AUTHORIZED UNDrR PPR m i'[, <br /> Cj 1.TANK'fNSTALLATION OR REPLAcEmrNy <br /> Q 2.PIPTINC NSTALLATION OR KGVLACEMEMT <br /> t <br /> 0 3.SUMP INSTALLATION OR RrPLACEMEN'T <br /> 0 4.UNDER Df';PrNSLR CON7A1NMFN*1,INSTALLATION OR RLPLACEMENT <br /> -0 5,QTJ WR <br /> DESCRIPTION OF WORK BFUNG C.L.'IcripLED: <br /> rc,\�-V of 1C) <br /> JH. CONTRACTOR INFbkMATION <br /> NAME OF CONTRACTORW110 PERFORMED INSTALLATION M001111CAT[ON <br /> (CIA 10 <br /> CONTRACTOR LICENSP.It eazb. ICC CIMWATION 4 <br /> (I(rCC 1(o <br /> JV, CERTTFTiCA ON <br /> I certify that ripe information provided herein is true,MlarAte,and that the following conditions have been satisfied: <br /> 0 <br /> • <br /> I-be installer has met the requirements sct forth in 23 CCR§2715.subdivisions(P,.),tnd(11). <br /> • The underground storage tank, any primary piping, and any `eCOndary 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 compIcted. <br /> • The installation 110-S been inspected and approved by the local kflenCy.Or if required by the 10ual agency, inspected and certified <br /> by a roistered professional engineer having.education and ex erience with underground storay <br /> te tank system installations, <br /> SbUNA,ruRL;OF TANK OWWI ()K OWNER'S AGENT DATE 4 497. <br /> 2n <br /> 0XIII-MUS NAMR(pint) ... CE RTWTER'S T11LE: <br /> NAME OF CERTIPII�R'S EMP1,0YER(DBA) 40. <br /> CF101HEX'S RELATTOWST-HP TO TANK OWNER <br /> Wj a (!b cyrr-, 0 1.TANK OWNER 2.TANK OPLIWAM <br /> -M,3.CONTRACTOR ❑ S.PROPLMY OWNER <br /> 0 3-OTHER AUTHORIZED ACi1*,N-1'(.)j,-rANK OWNER <br /> UPCF UST-C Rev.(12/2007).1P- www.un1dtw-q.oPr4_, <br />