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Feb 10 14 06: 44a Elite IV Contactors 12094616342 P- 2 <br /> Iq <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> . . . ....UNDERGROUND STORAGETANKFFFFS 1 O 2014 <br /> CERTIFICATION OF INSTALLATION/MOD] H'ICATIOIV— <br /> .. : .Iq .. <br /> I FACII II Y DVFORNIATION 11 F PAMENT <br /> FACMM ID#(Agmy Use Only) "- <br /> UYE'a, <br /> BUSINESS'AME(sm..grACWYNAMEnDBA-Doff" <br /> __....-. -BUSINES&SITE ADDRESS <br /> IL'INSTATIONlSVIODI ATIN PROJEC.I DESCR t'TION <br /> AT I t .. . <br /> TYPE OF PROJECT(Cheek all dot aoolvl 4R3e WORKAUCI )RIZED UNDER PERMIT 4Ml <br /> ❑ 1.TANKINSTALLA1I0NORREPLACF.MENF (Number o,r te): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER _ <br /> DESCRIPTION OF WORK BEING CERTIFIED; 40. <br /> wv)—x'- t V HE'I L l(o,,iL44 e?;- -�54 p?i x �t 't CLLt rtif <br /> lir 1A � 1` `"� C' <br /> � f&,n btu. ;+n"Ci R <br /> �Fu%1 ASF <br /> 1 -f <br /> �J'i� �;ti� ��1'G�`i,rc r�l;�n✓F) �i,:y1 � _ �>D �> <br /> vtu <br /> �' I�',•�j• '��/� ! f_ Jm L. 1�7�1�(,V'L I�A.C>',/�('n t'l�fl-. �'`n r ,n�i����l'�..`!d���%'.,'L. <br /> 7. <br /> 1YI COD177tAGT ?OYtMAiLON <br /> NAME OF CONTRACTOR WHO PERFORMINSTALLATION/MOD•CgT10N °N <br /> ell <br /> CONTRACTOR LICENSE# 4826' )CC CERTIFICATION# <br /> 3 <br /> F.(tT�IFIi"ATION <br /> I certify that the information provided herein is true,accurate,and that the following con 'itions have been Satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(It) <br /> - - _ 1lte underground storage tank,any primary piping, and any secondarycoatainmen: ,as installed according to app]icable <br /> --"- voldnt§iy consensus standaitis and-anymanufacturer's written instillation 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 ll :local agency,inspected and certified <br /> by aregistered professional engineer having education and ex rience with underground s nage tank system installations. <br /> SIGNATURE ANKOWNERO 'O NWSAGENT DAT-B. [ PHONE / <br /> 484. 4V. <br /> CERTIF 'S. (print r 485 CER IER'S <br /> o <br /> -"'NAME OF dsgTiFm,s EMGggqLOYER'(DBA) 40 CERTIFIER'S RELATIONS) It rOTANKOWNER <br /> ❑ 1.TANK OWNER ] 2.TANK OPERATOR <br /> 4 /, CONTRACTOR .. ].4.PROPERTYOWNER <br /> 71 <br /> J` (,. P / 1,%��( :(,� ❑ 5.OTHER AUTHORIZED, 3047 OF TANK OWNER <br /> . UPCF.UST.0-1/2. .. ... . . .. Rev.(1212867) <br />