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Rpr 03 02 08:18a Elite Contractors Inc 209461634,— p.l <br />to <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project) <br />L FACILITY INFORMATION <br />FACILITY 10 # (Agency Use Only) <br />-J, <br />BU (NESS NAME (&oreas Focrary Name or DBA—DoingBminew As) <br />0.�'Pr k'a e, <br />BUSINESS SITE ADDRESS <br />�YGI'I�QC �� <br />CIT"���J ra. <br />l LO S r C <br />[l i O Y1 <br />II: INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT(Cheakelltharaanl <br />WORK .AUTHORIZEDUNDERPERMIT 4 1%' <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Owe): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />`G,' QCis �jQQf� <br />❑ 3. sump INSTALLATION OR REPLACEMENT <br />❑ UNDER <br />DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENTEZ <br />' .a — „ t)� <br />S4. <br />. OTHER <br />t <br />DESCRIPTION OF WORK BEING CERTIFIED: <br />' 6 <br />) eI-P - �- -?V,�14 - i-tA, bc.Lck•1- <br />'$i= CgSbb--j (,LSL CQ .PnC 1:51nj drop +-LL a- i 'Re plcac�d r Iia <br />Co �tlt kiLclC•� hola.s s S(auor, letk ��5� <br />�1 <br />Mtn Im.ir- L sJ' l h r• <br />�� <br />I r`L k -Il C�pPCI JIJC�tt).tL <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION 1 MODIFICATION AUL <br />(...L �P— i V Covi+nxc4vra <br />CONTRACTOR LICENSE A � <br />ICC CERTIFICATION n 4M. <br />Say 8 <br />IV. CERTIFICATION <br />I 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 />• T46 installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />bif a registered proilLssiorial engineer having education and ex erience with underground storage tanks stem installations. <br />SIGN TUBE OF TANK OWNER OR OWNER'S AGENT <br />DATE 4N. <br />PHONE 497. <br />CHRTIF,)1 '-9N'AME rint) "B5' <br />CERTIFIER'S TITLE: <br />Te dh <br />;� CIt-C& <br />NAME OF CERTIFIER'S EMPLOYER (DBA) ' <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 4"' <br />t.... <br />i� <br />V O� � e <br />❑ I. TANK OWNER ❑ 2. TANK OPERATOR <br />[33.CONTRACTOR [14. PROPERTY OWNER <br />l/L <br />`Lol <br />OTHER AUTPORIZED AGENT OF TANK OWNER <br />UPCF UST,C Rev. (7212007)- 112 .".unidomorg <br />