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Rug 28 13 08: 43a ElitIV Contactors 120946342t', 1 n <br /> t (� U <br /> AUG 2 8.2013 1A <br /> UNIFIED PROGRAM CONSOLIDATED FO1-A <br /> UNDERGROUND STORAGE TANK ENVIRONMEr"— <br /> CERTIFICATION OF INSTALLATION/MO: IIFICATIOWLTH DEPARTh <br /> (Om Fwm pa pmject) <br /> P 1 <br /> FACILTIY ID#(Agency Use Only) 'y <br /> BUSRgEESS NAME(S..F�carr NA,_. M-Do6ra,ne—A4 <br /> BUSINESS SITE ADDRESS. CITY <br /> TYPEOF PROJECT(Chcck Al to I Ae3i WORK�.t HORIZF.D UNDER PERMIT <br /> ❑ 1.TANKINSTALLATION OR REPLACEMENT (Numbera Dm): <br /> ❑.2.PIPINOINSTALLATIONORREPLACM ENT <br /> El,3.SUMP INSTALLATIONORREPLACEMENT <br /> ❑ b.UNDER DISPENSER CONTAMM4T INSTALLATION OR RE PLACIRIENT `•L• _( �,Uf.' 9 <br /> AMS.OTHQt /v <br /> R OF WORK-MIND CFRTtFIED: _ 48" <br /> if <br /> � '{ � � ��� j,,rn ,•{.i(a. i'� 'tCi1Lj. C)?1l"r�.iL. �UX.I.t. I:�� __ L <br /> ez. <br /> `J.nAtE OF CONTRACCOR WHO PERFORMEO INSTION/MODIFICATION - <br /> . CONTRACTORIICENSE Y. wm IOC CERTIFICATION#. _ 482, <br /> - -- -I-certify-that-the information provided-herein-is true;accurate;and that the following-co. ditions have been satisfied: - - <br /> - The installer has mat the <br /> requirements set forthin23 CCR§2715,subdivisions(g)and Ih <br /> The wpdergrougd storage tank, any primary_piping,.and say secondary containment was.installed according to applicable <br /> voluntary consensus standards and any manufacturces written-installation instructions. <br /> .. ..All work listed in the manufacturer's installation checklisthas been compleW. <br /> "-....."..Tfi'itis�alfaiion has`lieeii lnspec"tad'ana appiove'd b`y tfie I'ocal'agency;or`if'?equired'b3 i e tiesC'agency,inspected end certified .. . <br /> b r d mfrs9ional en ' eerhavia education and enee with and and t -a=tank stemk8alleions. <br /> S1GKfArR8 OP TAW OWNER OR OWNER'S AGENT ;DA^1'E . . n4. 'PHONE . .wv .. <br /> C IER'S N ' t) .. .. 40- rlMTIF T1TLE: - rti <br /> reci I rY iJ ' _ irLj- <br /> ...q 1 TIF.1 HI . -Y it(DgAj .. ._. -.M CfiRTIP1Ht'$RELATIONSItb 1b TANK OWNER <br /> N OF CER <br /> f // ❑ 1 TANK OWNER � � ] 2.TANK OPERATOR <br /> { i (CONTRACTOR 4:PROPERTYOWNER <br /> I i ,: r !�I 11 ,.�]. •��/ ❑ 5.OTHER AUTHORIZE:). OENTOFTANKOWNER . <br /> UPCP TWC-12 Rev-(112007) <br />