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Jun 09 11 12: 01p Elite IV Contactors 12094616342P41�;`` p.1 <br />A, <br />�.. Y <br />•. {M •Xllw/O�M�r <br />Ln\TMD PROGRAM CONSOLIDATED 1; 0 :.A <br />Tlf!I DERGROUND STORAGE TANK <br />C+ R�`IC.A.'ITrON Off' INSTALL# TTON / li I )-DIFICAN770, <br />One form er. ro ect -. ' `°�• <br />, <br />FACILITY IDI (Agency Use Only) !I <br />$U AME{(SameacijiryAlune�rl&�4-Bwiness�s) - 3 <br />BUSTNESSSITE DRESS. 1Q3. �' ', _ iw. <br />TYPE OF PROJECT. {Checkali Thar �mnlvl : apa WORE; :"CE30RI21=1? UNFDER PERhIIS <br />• [] , I.TAMC°A�'STALLATION OR'REPX.AL'EMEN!': '. (�`f <br />Q' Z.PIPING rNSTALI:ATIox oR REP! ACIIviEt1l <br />-0..3.'SUMPiNSTALLATTONORREPLA'Cr IIT <br />Q'4:URDERDISPENSERCOxTAIIQMEA*TINSTALLATIOh'ORREPLACIIv <br />S: <br />OTFTER <br />{r <br />.:''-DFSC.h31".i70A1_OFWOR�EWG-C.cR%iF,IED:--,-. ---- -- -- -, --- .� ^, --- - - --•:( .-e�____.,__..�_.—_.. .�4�>...__..._ <br />� • `lV j l_�5 t <br />�f � � � /1 , ^flk. 1! ,�� ,,,It!� '�� .. J �• �1 �•rf I / 1 �r/�` lt��j �L! '`,.. , <br />ILI <br />Of,C CTGJ WI '0 P KNEED INSTALLATJON l MODMCATTON_ . <br />k4M <br />COA�iRACTOR LICENSE li atm . ICC•CERTMCAT10N# <br />I certify that the inlorma6on provided herein as.umn 2ccvi ate, and that the Wowing co: 4:ifions have been satisfied. <br />The�iusbllex•3:as�metthe-requzr=er& set forth: in 23 CCR,§2- B,:siibdMsions (g} and-th. <br />.. The underground storage 'tank, 'any PnmarY P and :aa3'..secandary..secondary-containment vas installed according to applicable <br />., - . -voluntary consensus=standards-and any,manufaciurees u� tten bismllation-vasfzuctions: <br />®: .All work listed in the Inanufhbfilrer's.instaffation dlecldisf"has been'.coingieted: <br />_ 'Tb.e iustafiation:has.b--'= inspected and approved:by the la t'a ency, or'ifrequired:by t :focal agency, inspected and certified <br />b a.' e istered fessianaf enjgmeez•. havizzg education and etaence with' un.0 s -ane tank instaffa6ons. <br />SEGNA OF TANK OWN)WOR OWNER'S AGENT.. IDA TE awe PHONE. � <br />• <br />... - - <br />,S �? •ate. s.Tr.�. - � : f .. <br />Al F CERTIFTFXt'S a M (DBA) CER�R'S REE ATION_SH �S' 1). T-A13K:O.WxI1t ' ' <br />T -M-OPERATOR <br />r:._ <br />�,� t. ..� 3: CONIiL,4CfOR .:.. ] 4.4'.ROPERTX OWNER <br />:S.'OTHE•RAUTHOPUM A 3OL aNT'OF�TANK OVi'xER' <br />-••�,r- ...UrCFUST-C 11er..(I2r-007)--I/l.'. <br />