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Feb 12 09 02: 41p Elite Iv Contractors Inc 2094616342 P' 1 M N <br /> Nva. <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �p <br /> CERTIFICATION OF INSTALLATION/MODIFICATION 2 2009 <br /> (One form Per project) <br /> FAC=..Y 1NF0R9ATIO1R: y tr Av g �Q�ti)y z <br /> FACILITY ID a(AbmnayW Onl)'1 <br /> BUSINESS N anis as Faci' Naue Or Or Doi,y;flueinear A,) e 1 �. <br /> BUSINESS SITLADDRESS I4 <br /> Ia), C <br /> 14 <br /> _ . <br /> M.Y'NSTALLATI /MOl)JFICATION PR09ECT DESCRIP7 XO1V ' <br /> TYPE OF PROIECf(Camk w'Ll aLaCt,' '"�` WORK AUTHORIZED UNDER PERMIT +uo <br /> ❑ I,TANK INSTALLATION OR RRPLACEMLTrI' (Numhcr nr Date): <br /> ❑ 2.PIPING INSTALLATION OR RP.PLACI:MENTEl 3.SUM'INSTALLAMON Oft REPLAC�.Mr-;N7 <br /> ) ` <br /> ❑ 4.UNDEI DISPENSLR CO TAINMENT INS ALLATION OR IMPLACEMETT <br /> ❑ 5,OTHF.R <br /> DRSOJUPTION OP WORK)MING CRItTDrIED: + <br /> c (.( .1j'Jc� llvl.(��� <br /> 7YGjl. (a efdr ,:fit i�(N, A i IL F l' �` � � 4.XI`�� ..1 �j���, -(C <br /> .nL CONTRACTbk&FORMATION .' <br /> NAME OP CONI' R WHO 1'WU'UKM RD INSTALLATIUN/MODp+)CAT10N <br /> � aX:u <br /> MO74 <br /> CONTRA47,RZCEIVE K-� / .xa. ICCCE1tT11ICATION <br /> 1 V:;.CERTIEICATION ,- <br /> 1 eertifv that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has mct die requirements act forth in 23 CCR§2715,subdivisions(g)and(h), <br /> • The undetground 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 manufacntrer's installation checklist has been completed. <br /> • rn <br /> The installation has boinspected and approved by the local agency,or if required by the loCal agency, inspected and certified <br /> by a r tistered fessional engineer having education and experience with undcrzround stoma c tank system installations, <br /> SIGNATU OI'TANK OWNERpR OWNPIR'S AGENT DATE +a+ PHONL <br /> CERTIFIRR'S NAME(print) t 4�' .CERMFI S - 4a,. <br /> NAME OF CL TIFiER-S U4P1.OY BA sten. ew, <br /> (D ) CPBTIFIlili'S ItL•LA7'IUNSHIP Tp TANK DINNER <br /> Z f <br /> G '� ❑ I,TANK O W NER ❑ _,TANK OPERATOR <br /> 7 /'ter y ❑ S.CONTRACTOR ❑ 4.PROPER'IY OWN).R <br /> 5.OTHLR AUTHORIZED AGENT 01"TANK OWNER <br /> UPCF UST-C Rev.(1=an-112 ww ,unidoea.arg <br />