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Oct 22 10 08:05a Elite V Contactors 120946 6342 P.1 <br />-77Z7 <br />UNIFIED PROGRAM CONSOLMATED FORITI <br />UNDERGROUND O. <br />IF�. �'�> <br />• rt . a .Fy <br />0 (Agency Use Only) <br />BUS (Same7al Wry N BA—�Lng Business ArJ 3. <br />I <br />TYPE OF PROJECT {Cheek all that anz71v1 �'� WORK AUTHORIZ `�ER PERMIT 483b. . <br />❑ 1. =INSTALLATION OR REPL,.ACE MNT . (Number or Dace): <br />Q 2. PIPING INSTALLATION OR REPLACEMENT <br />❑. 3. SUMP INSTALLATION OR REPLACEMEA*r <br />Q.4. UNDER DISPENSER 'CONTA.INMENTINSTALLATION OR REPLACEMENT C(lnJ <br />Q <br />5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFFM: , ..... _ 463a <br />. <br />k1 J, <br />Ott lolt6u�l peni <br />IST I -)I <br />f <br />CO ORCENS00 `t , f � ° ' ='CERTIFICATION # 4M <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has islet the requirements set forth in 23 CCR §2715,:subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any.manufactarer's written installation -instructions. <br />• All work listed in the manufacturer's installation cheeklist has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by axeVi=M1jvDfessj2gka&eer having education and experience with underground storax tank system installations. <br />SIGNA OFT ���SGENT DAT6/ ' 414. PHONE_ � � R� 497. <br />CERTTFCER' NAIvI$ (Print) ass. CERTHMVS TIME: (/Q / 48& <br />N OF CERTIFIER'S EMPLOYER (DBA) CERTWIER'S RELATIONSHIP TO. TANK OWN449' <br />L TA3�IIC OWNiR 1]"2: TANX-OPERATOR <br />0 <br />3. CONTRACTOR 0 4. PROPERTY OWNER <br />F(! ❑ .S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />ITPCF UST -C Rev. (1212007) -1/2 v&ww.unidoes org . <br />