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1%a 18 14 02:13p Elite Iv Contractors Inc 209461Cq42 p.2
<br />RECEIVED
<br />'UNUUD rn4tyRAM CONS&MATED FORM DEC 18 2014
<br />UNDERGROUND STORAGE TAMC
<br />CERTIFICATION 'OF INSTA,L LA DON / MOD RN
<br />(One form.perprgject) �NMENTAL HEALT
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<br />BUSINess NAtdli (Same as Fnallry Nomc or DBA- DoinLRai
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<br />TYPE OFPI1Qp CT (Check all rharanndvl WORK AI;THORIGED UNDER P RMTT
<br />❑ • 1. TANK INSTALLATION ()It RL:11LAC WENT (Number or Dau);
<br />.❑ 2, PIPING INSTALL,A'nON nR7tii1 I:ACMAENT
<br />(�] 3. SUMP IN.STALLITION OR REPtACEXSNT
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<br />4. UNDER DISPENSls'it CONTARN*MENT INSTALLATION OR RULACLMPNT i {
<br />ESCftL•fION OF WOkK 1ILiWG LMtTMFD: _ " �• '---
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<br />CONTRACTOR LICENSE IY ,
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<br />I certify that the information provided herein is true, accurate, and that the fallowing conditions have been satisbed:
<br />The installer has mel the requirements set forth in 23 CCR §2715, Subdivisions (g) and (h),
<br />• The und0f9mund storage tank, any primary piping, and any secondary containment' was installed according to appiiCable
<br />vOluntary Cppyensus standards And any manufacturer's written installation instructions.
<br />• All work listed in the manufacturer's installation checklist has been completed.
<br />• The insitilMon has been. inspected and approved by the local agency, or if required by the local agency„inspected and certified
<br />by a i'e 'stered rofessional engineer having educmicin and cx cricncc with underground stora tank SYS tem installations:
<br />SIGNATU F TANS-OWNEWR iPWNPR'SAGENT DATE 484' PHONE +97•
<br />CER S N $(print) Ns. Ci"RT1FiER'S TLTL£: o
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<br />NAME OF CrkTWBR'S EWLOM (DBA) • °RK' CL•RTIFIEWS RM.ATIONSHIP TO TANK'OWNER we
<br />'❑ I.TANK'OWNIIR:' 0-1 TANK,01T.ItATOR
<br />i -,iTZ3. CONTRACTOR
<br />❑ 4. rROPraTY OWNIGIt !
<br />❑ S. OTHER AUT1IOR=:A0MTr OF TANK OWNER �
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