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Ru.- 01 12 12: 44p Elite IV Contactors 12094616342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED T( 3M - <br /> UNDERGROUND STOR4GE TANE - <br /> CERTIFICATION OF INSTALLATION Rd -)DIFICATION <br /> ,(One fortniw projeo). <br /> MR <br /> '��y s.5�'-' �iRh.#r� '" '^:' - sem-•+s.¢. - a� vi,'ria"a%+C'% .x�g.'�:=°' .y ;�3"__sexy-;<. <br /> FACIdIY ID#(Agr Use(alq) _ l <br /> BUSD1ESSNAL(E(&wwFanliryN.m a DB.I—DoingBusrtcvAs) -- � - �3. <br /> C <br /> BUSINESSSITE ADDRESS - <br /> i tie (Yicllek� tilYlei Sfzttxrv- 34 <br /> rpt.. '.1, 4 _ i w.�ar_ 'i1� EI •rm _ ""-ew'�yz.�sFS•.. <br /> TYPE OF PROJECT(Cheek allaw®nlviX _ - ° WORK IITHORUED UNDER PERMCC <br /> j] 1.TANK INSTALLATIONORREPLACEMENT:. :' - (Nanbt iwDme): . <br /> .Q'2,Y]PING RISTALLATIONOR REPLACEMENT' <br /> Q.3.SUMP INSTALI.ATJON OR REPLACEMENT <br /> [].4:UNDER DISPENSER CONTAINMENT INSTALLATION ORREPLACgd]!N• <br /> --_.--- DE$CRII'1'ION.OFWORK BEING CERTIFIED: <br /> Coil tl tcb�r4�S ix� 51rJ 4 .r ,i�rns11yC? <br /> tYxsl� talc 5km �e! tKct umk <br /> re6 �feci rnc�i kl r u�c� ��t� k re . ; ups m*j 2.3 e • <br /> ..A ...'^-vE 4 t • i.[$�'A... i fN. _- L"Yi.—r C'CtY t' <br /> - NAtg OF CO_NTRACTOA WNOPERFORMED INSTALLATION/MODIFICATION area,. <br /> CONTRACTOR LICENSE# 40b. ICC'CERTIPICATION# — - 4� <br /> Le(1 CrQiCa .0"2 H2, <br /> �i4F 3 F Sr <br /> I certify that the information provided herein is true,accurate,and that the following :t t ditions have been satisfied: . <br /> . .: 9 :The installer has met the requirements set forth in 23 CCR§27.15,subdivisions(g)and.(I <br /> The underground storage t3r� any primary piping, and any secondary coutdnzncai was installedaccording to appbc*we <br /> --..voluntary consensus standardrand any manufachaer's written installation-instructions. .-. .. - . <br /> • All work listed in the manufacturer's insWlation checklist has been completed. - - - <br /> The installation.has.been inspected and approved:by the Iocal agency,or if required b:r a;local agency,inspected and certified <br /> aregistered prafissional en ' cer having education and exDerituce With und tm,i; a tank- -emiastatlations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT- - _ - -DATE'.. _ - +s+. PHONE <br /> CERTIFIER'S N 1 iu.. CER77MVS.T=— <br /> NAME OF TIFB]t'S E eLOYER(DBA) CERTIFI ER's RELATTONSIM ]O TANK OWNER <br /> ;1] LTANKOWNEW j]'2 TAMC-OPERATOR <br /> 59:�!-i 1.!• `SQ.CONTRACTOR 7 4.PROPERTY OWNER <br /> . .. . 5.OTHER AUTBORtZEU_. TINT OF TANK OWNER <br /> mitt UPCF USIL Ra+. - - <br /> . . (11x2007)-32 - www-mid�cara <br />