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Oct 23 08 12' 54p Elite Tv Contractors Inc 2094GIR342 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK OCT 2 4 2908 <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) SAN JOAQUIN COUN <br /> L FACILITY INFORMATION EIEALTH DE1' R-rMENT <br /> FACILITY 1D!#(Agency Use Only) TT. I T F-1 F . <br /> I' <br /> BUSINESS NAME(.Sartre as Facility A'ame or DBl1'-7Joing Business As) 3' <br /> ( �(1�J I f I f1 iaL f <br /> V ? <br /> BUSINESS SITE ADDRESS r r a tui' CITY ! y lus' <br /> J LJ Inc��i� <br /> II. INSTALLATION/ ODIFICATION�ROJECT DESCRIPTION' <br /> TYPE OF PROJECT(Check all thal aaoly} 4113.. WORK AUTHORIZED UNDER PERHUT axle <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> Cl 3.SUMP INSTALLATION OR REPLACEMENT r , <br /> ❑ 4.UNDER DISPENSER'CONTAINMENT INSTALLATION OR REPLACENfENT41 <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: e 1, r C483`` <br /> '��f" <br /> r � <br /> X/i. ;. ' r. <br /> rte <br /> VANE OF^Ct�TIUAC ORJ,NVHO P RMI:L7'INST4 CONTRAD OIt jNFORIVIAT`ION" <br /> MODIFICATION <br /> aszz. <br /> CONTRA .OR LICENSE 4sxZb' ICC CERTIFICATION'ftas <br /> l fl ,n �� <br /> IV. CERTIFICATION <br /> 1 certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met 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 manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist 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 a 5agistered professional ennineer having education and ex erience with under ound storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT STATE f f 4u. PHONE <br /> CERTIOIEWS NAME(print) } ss'' CERT[ 1ER'S TITLE: /� aae. <br /> aHs. 4M <br /> NAME QF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> © 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> LJ ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> L <br /> UPCF UST-C Rev.(1212007)-112 www.unidacs.org <br />