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Aug 17 12 11 : 00a Elit IV Contactors 120946 342 p. 2 <br /> n 'a <br /> UMM <br /> L'PROG CONSOLIDATED.yt RM <br /> ��j �.�.+{�..((.�' . .UNUERRjGROUND�S(T�®RAGEf�7CNAhfI{.`/ /l�g j (�A. {(J <br /> ' .CERT .RCATIO 1 OFINSTALLATION t / ..P. 6,$�,JFA'JLL..d'7�.Ji$ON <br /> FACILITY ID#(Agmay Use Only) <br /> BUSTIJESSNAIv1E{Same�FaaliPyNamearDBA—DoiMgBusir ssAsJ .-. a <br /> BUSINESS SriEADDRESS io3. CITY: ion. <br /> Xlzk C-jhao� . La1o� <br /> TYPE OF PROJECT(ChecFttit iv1 0. WOI1 k TTHORMM UNDER PERMIT -4 <br /> Q I:TANKINSTALLATION•ORR&PiACEMENT (NuiaP rorDate) <br /> ❑2-PIPING JNSTALLATION OR itEPLACEjAENT ������) - / <br /> _(.3.Sumr RwALLAnoN OR REPLAcumNT } l.Jl:{y L� <br /> 4.UNDER DISPENSER CONTAnO43NrT.INSTALLATION OR REPLACEN9VT. <br /> 5.OTHER <br /> =----- AESCRIETIONLORWORKBENG.CERTffUD. <br /> inn <br /> : <br /> isAn1E of CONTRACTOR Q6'HO PERFORMED INSTALLATION/MODMCA.TION. . as2ti <br /> CONTRACTORLICENSE 4=b. ICC.C8R7YFICATt0N-# .� r} "me. <br /> CJG�C� X 43 <br /> I certify that the info ion provided herein is true,accurate,and that the foflowinl:c ndlitions have been satisfied: <br /> : . -�-The-kstailsrkas:met tiLwT gairements set forth,in 23 CCR§2715,subtfzvisions(gj <br /> ® The uad d storage. anY pY.Pd:any..secondaxy, eoniamm . was installed according to applicable <br /> vohuatarycoxiservs staBclsrds and -Pllou uviitteu iusfation instxvctions <br /> a :All work listed in the m 's•installation checklisthas been completed <br /> The,installation..has becn' and.approved;by by-i6 local agency,or if .try tie:locat agency,inspected and cal ified <br /> by a stered rofsianal engineer ha educadaa and encs With one�d 7 nm--e tank em installations. <br /> SIGNATURE OF TANK OVIM'OR'OWI�WS AGENT: DATE`.' asa. ' PHONE �4M ' <br /> CER.T&M'S N 1 CERT 'S;TT.t7.E: r <br /> ass. asp. <br /> N4W OF TIFIER'S MOLOXER(I)BA}.` aa& CER-DFTTER'S RFd:A2T(IirIC H 'TO:TANK'O 4".. <br /> .: <br /> ❑ I.TA3+1K OAtNER '2 TA-M-OPERATOR <br /> rL <br /> C�'IC�ECC1(`5 `1G ❑3.CONYRAGTOR 1� a.PROPERTY OWNER <br /> Q'5.QTAEKAIOTHORIZ:]a c TENT OF TANK OWNER' <br /> x: UPCF UST=C'Fm.�(I2/2on-IJS ww�w•.4uehi—rg` <br />