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Jun 15 10 08 41a E Elite IV Contactors 12094616342 p. l <br /> i U ' 1 z O O 1 UNIFIED PROGR�IM CONSOLIDATED FORM <br /> U"ERGROU.ND STORAGE TANK <br /> C RTJ `ICAaJ ON QF`INSTALL_A TON 1 <br /> �: 1l�tODMICA:' `SON <br /> Oue form;per.projixtj.._ <br /> k <br /> VIA <br /> x ' <br /> FAC)L1IY M#(Agency Use O?zW <br /> B $ asDr DBA <br /> Eme Feyliq� a»re -Dohxg-a-h sds) " <br /> �/� l 3. <br /> SS (Sa <br /> xU ` S5MAD Rte. [L <br /> 103. t- 1 <br /> •-� `.�:xx -:vrm ?�� ru <br /> w �-'�y:>.. :;•a+ � � QRTZED L7NDi <br /> TYPE-OF PROJECT:(CL¢kall a5atamilv). <br /> 4D&-. .WORKAUM ERPERACT b. <br /> g 1.IAIK INSTMI AJION OR REPLAC M-rr: (Nuco r of Dam) <br /> PIPIIJG?JZSIALZAT70N:QRREBLACEMENI <br /> . . � 3.SUMP Ri'STfiLLATION OR R�'L.A�T ` <br /> •D:4:' NDMLDISPENSER.•CONTAIIJMENTDMALLAnONOR'REPL14Cav�Tf•.: (J�,((J.L/�W <br /> ESCSON-OF�JAR£.BEING.CEILT-�D:- <br /> .`��• . 1 �t.•C,t"off c�;�e�J •..�•�'j . - • `l - . . . _ . <br /> W1 <br /> ocl%rle <br /> �� � . <br /> ,mac"' <br /> ✓+ ..�.��� -,.,.era _�..t�_. .• Ya^,��'!�"���•:'_.-1 . <br /> -� . . �.icdr Hast. .... r�.uvBa n m*�.'. �.cwa.�s.,,..ms.u:_.. ._. �f . <br /> NAME O CONTRACTOR WHO PERFORMED INSTALLATION.!WDiNCATION om <br /> COTrJR:SCI OR I 1 asm lCC'CERTMCATIQTi# 40c <br /> IWIM-1-1511 M. N. <br /> .1 certify*at the information provided herein is..trn"ccurate,and that die.iollowi�conditions have been satisfied: <br /> ert <br /> •' The instaticr hasmer'thc-mquneIIts sef fortE in 33 CCR§i715, (g).and <br /> :.. The-undmZm and:stor2p..-tank, any pn�y.piPi q,—,z d..any.secondary-conWnment-.vas.inst0ed'according to applicable <br /> - voimdagrousausur�stmdard andanyniaunfacturer'svmtieamstaIlstioainstiuctions.: .:: : <br /> •: '.All wori`listed in'the manufacfiries-instaMon-ehecl w—has:bgen'-i ompleted <br /> .. _'The:installation.has.bspted`andappmved bythe local':agency Qr`ifre�vue :by#tu local agcney,inspected and certified <br /> a- education anderience 9vith uadci and tank installations. <br /> SfGN�4 OFTANK O OR'OWNER'S.AGEhrT'•. DiiTE•'':. ac FfIUNE. 4U,. <br /> l�J <br /> _.y. ` <br /> •S <br /> N. AME OF CERTMER'S EMPLDIM(DBA};'� ENK-OWNER <br /> IV co <br /> € D;3.c -crop :. n'a�xazX oar <br /> f. rI`G�v.. 'AUT H0PJZ.IDAMN`T•t)FTANKOWJ4FIt`' <br /> „: ,vPOp•DS3'=C ; 07),+iA.982 :..xwKainideci.*M.. :. <br />