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May ,2�7 11 11 : 24a Elite V Contactors 120946 342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FOO ►t <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATTON OF INSTALLATION/M( JDIFICATION <br /> (One form per project.) <br /> _...... ._...._:........ .... ... ,. .. ..._ _.............X...,�sA �'Y.XI�[F,OR,Mt�Tlal�:_ - <br /> FACILITY ID#(Agency Use Only] <br /> O$INESSNAME(S..FMu\� <br /> M�orDBA-Doin&Business As) - V`7 <br /> � � oiS <br /> BUSINESS$ITE ADD S laj. CITY loe. <br /> - `���• ����' i ^ � �C� CSC-u <br /> 0.: ., ..... ,. ._.... ..... .... ...�. _. .... o� ....._.x�:-��Ana;. rW°rrfl - <br /> TYPE OF PROJECT(Check all that apply f 483a won:A HORrzED UNDER PERMIT 493b. <br /> ❑ 1-TANK INSTALLATION OR REPLACEMENT (Numinr r Nate): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT (� <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4830 <br /> rnmi <br /> 0100-ellb �b "I , <br /> Odd - orm- orl <br /> NAME C OR` P O IN TALLATION/MODIFICATION 4M <br /> £ <br /> `tea FIL <br /> CONTRA OR LI SE# 482b. ICC CERTIFICATION 4824. <br /> l - , <br /> , <br /> Z <br /> c <br /> k <br /> _ a <br /> O .. <br /> I certify that the information provided herein is true,accurate,and that the following co. ditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§271.5,subdivisions(g)and f <br /> • The underground storage tank, any primary piping, and any secondary containment ??as 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 t -. local agency, inspected and certified <br /> re istered rofessionaI engineer havingeducation and ex rience with undergrountZ s e tank s stem installations. <br /> IGNATURE O OWi\ 'S AGENT DATE PHONE 4sz. <br /> CERTIFIER'S NAME(print 485 CERTIFIER' TITLE: 486. <br /> NAMECtT F 'S EM OYER{DBA) 4ss CER IER'S REI ATIONSHIF '�TANK OWNER 489. <br /> �! / <br /> �+ �/ �I ❑ 2.TANK OWNER :1 2.TANK OPERATOR <br /> lr� l� t(,C 7'L""(•n Er-3—C—ONTR4CTOR :I 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORImr.4 ;ENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev,(I22007) <br />