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Nov 01 11 07: 54a Elite IV Contactors 12094616342 p. 1
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<br /> UNIF.l;ED-PROGRAM CONSOLIDATED::l P .
<br /> UNDE 1t 10'UND STORAGE 1 ANI: i
<br /> CER�`IFICA'T ION'OF INSTALLATION/ %/: OD.TFICA.'Wd
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<br /> FAClLr1Y ID#(4gency Use Only) e'
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<br /> :BUSINESS-NAME(Same as Faeiliry IJame'ar DBA—Doing Easiness ArJ
<br /> -BUSINc..SS•SnE ADDRESS �- 5- To
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<br /> 4UTHORIZEDUNDERPERIvIII
<br /> yTYPE-OFPROJECT(Ch=k9thaan
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<br /> (Na ai :or Date):
<br /> 0.1.TANR'INSTALLATION OR REPLAC",EMENf:,
<br /> 0 7-YINNG INSTALLATION'ORREPLACEMENT.
<br /> il'.3.SUN2'IIISI'ALLAMON ORREPJrACEbJENT \ 'i
<br /> 0:4:UNDER DISPENSER COATAI&0NT INSTALLATION OR REPLACEMENT.
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<br /> 'NAME OF CONTRACTOR WSO PT..RFORMID FA'STALI-AT)ONIMODIFICATI .
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<br /> C aszb. T'1FIGATIOA''s�
<br /> CONTRACTOR LICENSE I FCC'
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<br /> I certify that the.inifor�ation.provided here is..true,accurate,.and that the foIIovvin;; rnditioins'has�e been satisfied:
<br /> 'I'lieinstaller'has-metthezequu'ementsset forth.in23CCR§27.15;:subdiviszons(g)and �l: d according to a nlicable'
<br /> The under ds stora;e tank,'any primar, PiP�gg, and.any secondary cont=1e t•a�as installs p.
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<br /> -votuntaryconsenswsstandards-and any,�manufactuer'swritten,uistailiti' anstriictiorr:;.
<br /> All work listed in the manufactuter's.iustallation ohecllist has'been.compl ped'' ected d certified
<br /> T1ie,instaIlation.has been inspected and.approved:hy the Local a,_* .,:ovif required b: Ise local agency,insp
<br /> b- a:' shed fessional.enQinear havinucation and a erience with and of n• stord�eO em'instalIations_ asv,
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<br /> OF TANK OWNER OR OWNER'S AGENT: "....
<br /> SI DATE .
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<br /> — - 456..
<br /> ..CERTHUER'S,TnL7E:
<br /> CFRIIF
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<br /> a5a ' CER7I W.S'REL:A-TIONS3 1'.TO.T.OMO'DWER
<br /> NAME OF CERTIFIER'.S EII&L:O1'ER(DSA)' o q K-OPERATOR
<br /> C:�1 �i NT ltJi...:R PR TY OWNMER
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<br /> E a?GENT OF T.A$iK OWNER`'
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