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Apr 26 12 06: 07a Elite IV Contactors 12094616342 p. l <br /> R <br /> UNIFIED PROGRAM CONSOLIDATED F01 Irl <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/All IDIFICATION <br /> two #I (One form per project) <br /> FACILITY ID#"(Agency Use Only) <br /> MINOS N (sameP <br /> ¢.rrrxna�'oi�BA-noingaus �sI 3. <br /> 'ti lrur - . c_ <br /> 13uSINESS SITE ADMw3. C 104. <br /> TYPE OF PROJECT(Check all that apply) 483x. WORE.6 )THORIZED UNDER.PERMIT 4836" <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT- (Numl ei K-Date): <br /> ❑.2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑.3.SUMP INSTALLATION OR'REPLACEMENT C <br /> [14 UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT S � r�OCA4(cam <br /> tDESCRIPTION OF WORK BEING CERTIFIED: r J � 483c <br /> fro. (b-6 &'y. of r 4' -�l'•? Z �f <br /> t <br /> • „��.���.,�. �-- �- �� . ��"',� .� h�c�.� eta�+r� .. ��,��c� ,,Q�.� . <br /> . . . . . _ .: . _ .. APR 2. 6.20.12. _ <br /> s i ru k.. <br /> NAME OF CO R O PT ST TrI}ON}/,�"�ODIFICATION r "� <br /> � I t!0 ENIv P0NW,EN`��L <br /> C. _ LTA DEPART E T <br /> CONTRACTOR LICENSE# �C" Ick <br /> 487.b. ICC CERTIFICATION# 4820. <br /> - <br /> I certify that the information provided-herein is true,accurate,and that the following r:a ditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and'l <br /> • The underground storage tank, any primary piping, and any secondary 'contaimnelf ivas.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 /> • Th installation has been inspected and approved by the local agency,or:if required by i ;:Iocal agency, inspected and certified <br /> b r istered professional engineer having education and experience with undergroundL., prage tanks stem installations. <br /> SIGN RE OF TANK OWNER OR OWNER'S AGENTDATEf f Gl 494., PHONE <br /> G / -��48�2 <br /> C ... lER'S N (p1 t✓�/t US C1rR $TI rLE T f 486. <br /> �re� <br /> rAkE OF CER TIFTER'S LOYER(DBA) 44B -Cj2kIVIER`8 RELA'I'IONSI til TO TANK OWNER. <br /> © I.TANK OWNER :1 2.TANK OPERATOR <br /> 3.CONTRACTOR _.l 4.PROPERTY OWNER <br /> ElS.OTHER AUTHORIZEI). 'ENT OF TANK OWNER <br /> UPCF UST-C-In Rev.(12(2007) <br />