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Dec 01 08 01 : 38p Elite jV Contractors Inc 2094GIG342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> L`.'FAC <br /> II3TX.INFORMATION <br /> FACILTIY ID NWe-ry Use ON,) :•l„ <br /> HUSM"'S NAME(Same ax Farili Name"DBA-Darnp B",o As) <br /> 14.- <br /> h16A�l "n - <br /> auSlNt'' s DO 'sM, INSTALLATION/MOI)MCATION:.ftbibcT DESCRIPTION <br /> TYME or•PROiECr t k a am rv) •xr "wORKAUTHORJ=t1NDRu ML7ON OR REPLACEMENT (Number"Dare); <br /> ON OR RRPLACEMENT <br /> NOR RF,PLACLMENT <br /> CONTATNMLNT INSTALLATION OR REPLACEMENTIOSCRll'TIONOPWOR <br /> ob I <br /> . � II , <br /> 1L�l� •- � �I:. t /G O <br /> m. 0�5TRtnCTOP INFWZ zATkoN' <br /> NAMF OF CONTRA O O ;[iKlO INS7 LA ON/ ODIFIC 'ION <br /> CONTRACTOR :N, •'u• Ice eettTtmenTro <br /> • <br /> . <br /> N,•CEItTIE'I•CA'I'RUN ... ..:,. .,:• : ..: .:. .. :... .... . .. <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The inStallcr has met the requirements set fortb in 23 CCR§2715,subdivisions(g)and(h). <br /> • The under1,TOtnd storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary eonsenSus standards and any manufacturer's written installation instructions. <br /> • All work listed in the mmufaeturcr's installation the-Dist has been completed. <br /> • The installation has been inspecicd and approved by the local agency,or if required by the local agency, inspected and ccrtificd <br /> by a registaled fecsfonal rn inecr Kevin education and m erirnuc with unde and stem a tanks stem installations. <br /> SIGNATIIKE OF T WNEK UR OWNLK'S AGENT DATE PHONE rat. <br /> -ozs <br /> CGRTIRER'S NAr.(print) C04Tt1��`P�t 5 T1TLIi: yea. <br /> NAW L IFjL'S L'MI•WYER DH oxx. <br /> • � ('tiRTIFIFR'S RELATIONSHIP TO'IANI: R'NEIi <br /> 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 0.7.CONTRACTOR <br /> ONTAAG❑ 4.GNT•OFTANK OWNFut <br /> UPCF USTC Rev-(132007).12 wvnv.unlaocr.or� <br />