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RJan 07 14 01 : 54p Elite V Contactors 120946342 ^ p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED..Et 12M <br /> UNDERGROUND STORAGE TANG: <br /> CERTIFICATION OF INSTALLATION/N ODIFICATroif t I () 7 <br /> (Onefocm.perp;oject) ... . <br /> . -` <br /> rocwya.00 '3:;. <br /> CM <br /> FACILITY ID#(Agency Use Only) ), <br /> 1 <br /> r. <br /> BUSINESS NAME wF=11tyNo_or DBA-DoingBwiniw As) <br /> _ R <br /> BUSINEss srrF ADDRESS 103 C[TY LBONN <br /> ��_._, <br /> V ii9R.a5[R' M � !tkf4 :.4F S/q S;Y. <br /> 5 7_ -atVwN-&?TYPE OF PROJECT(Check-11 Phar ana(vl- U AUTHORIZEDUNDERPERMIT ^s3L <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT n.rorDate):❑ 2.PIPING INSTALLATION OR REPLACEMENT '�j�9❑ 3.SUMP BJ ISPENSM C OR D44ECEMENTY✓ /❑ 4.UNDERDISP£NSERCONTAA'MEN'f1NSIALI.ATIONORREPIACEMENf <br /> 5.07HERR . . - <br /> DESCRIPTTONOFWORKBEINGCERTIFIED: .. 40° <br /> fit` 6- TT) , <br /> �tCUEU &k.X MCNTCZlc -L 5\(S TEM MTC:,E .. <br /> Cit iF�j (-)F 5,1TF,' iARiEIN3� - <br /> .N - a � <br /> " .. .. MM <br /> _ <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION. - 41U <br /> CONT1tACTOR IJ SE# 0630. ICCCERTIFICATION9 <br /> '�' GP' d F ,m¢ n.. ..tivm wou. sac aw✓n �* � '�,� •�° <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)ar,d b). <br /> .. The underground storage tank, any primarypiping, and any secondary conlaimit t! wasinstalled 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 b :the local agency, inspected and certified <br /> b a 'stercd Professional engineer havin- education and experience with undzrgroim storage tank stem installations, <br /> -SIGNA FT O R WNER'S AGENT DATE — W. PHONE <br /> .- CIBt 'SN (print) n'...... - .acs. .=CFiRT1F]ER:S TITLE: - - _..- .... .- : 4as. . <br /> NAME OF CERTQ+ffit'S EMPLOYER(DBA) - r aet- CERTIF)ERR'S REI:ATIOI"S IP TO TANK OWNER 4"' <br /> T�- �S,f ��` ZL��. I ,t1`�� [] 1.TAMCOWNER.. E1'2.TAbM-OPBRATOR _ <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> 5.OTHER AUTHORME 'AGENT OFTANK OWNER <br /> DPCF UST-C Rev.(1=007)-112 w .nntaoecorg <br />