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Dec 17 13 09: 19a Elite IV Contactors 12094618342NED <br /> 2 <br /> RE Cff <br /> 'UNMED PROGRAM CONSOLIDATED FOR :f. <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF IlNSTALLATION/MC DMCAF�ONMENTA <br /> One form..er ro ectj. H_ L H DEPARTMENT <br /> C. . P . P. J. <br /> cn`7t CL +'4^�.K..�4i rtt•..-,.,�r•r•t r 9-:sa hn <br /> FACILrFY ID#(Agency Use Only) <br /> BUSINESS NAME(Smear Aaamy Name orDB.!-Doing Bus6rers As) 3. <br /> BUSINESS SITE ADDRESS CITY 04 <br /> -w „u• ' � x nrs�s e.�s s � <br /> Ih.a:.. &+ z. . low�, �'.'�tl' <br /> TYPE OF PROJECT(Checkall that mmhJy 4MWORE A. ITHORIZBD UNDER PERMIT as3b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Num:er r Date): <br /> ❑ 2.PIPING INSTALLA77ON OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4:UNDER DISPENSER CONTAINMENTINS,T� ON OR REPLACEMENT <br /> 5.OTHSR f .' - - - <br /> 4S3c. <br /> ESCR.IPTION OF WORK BEING CERTIFIED. <br /> IY1S �.S' � 'E.1�C �� � Sill. bt.'CK.ta � ���•tv'Yt1i1�-`, �� <br /> tt It7circa ,n W50i1 Rom K <br /> w ++ <br /> MINIMS, <br /> 1 - <br /> �}#f <br /> c:... _ <br /> NA.IAE OF CONTR.4CT'OR WHO PERFORMED INSTALLATION/MODIFICATION 492` <br /> mss„) <br /> -+�. , a�rsia�'•'4 � <br /> a's482r.CONTRACTOR LICENSE# j 6 b -IL <sb. ICC'CEATFICATION# <br /> h Na ��l 3i <br /> „ <br /> )(certify that the inforaistion provided herein is.true,accurate,and that the following c nditions have been satisfied: <br /> The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)anc.( .). <br /> The.underground Storage tank, any primary piping, and any secondary containtn:t 'was installed according to applicable <br /> voluntary consensus standards and any manuf'acturer'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 try he local agency, inspected and certified <br /> by a kc 'stered professional engineer having education and erience with under ounc Ao tank system installations. <br /> S1GNA P T O R WNI7t'S AGENT DATE 484. '11 4C. <br /> Z-I �/j 12 Ick <br /> 'S NAME(print). ..CERTIFffit'.S:TJTLE . <br /> CER 489. <br /> NAME OF CERTIFTER'S EMPLOYER(DBA) <br /> CERTiFF1ER'S RE[:A1TON:>F ?TO.TANK OWNER <br /> L��1`-' L"�_Cc � � J ( 0 .►�v: I TAJMOWNER' I <br /> 1&3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTH&R AUTHORIT.31 kGENT OF TANK OWNER <br /> 4.r- (TCF UST-C Rev.(1212007)-Il2 www.uWdots orR <br />