Laserfiche WebLink
Jan 24 12 01:51p Elite :V Contactors 120946;6342 gam,_ p.1 <br />UNIFIED PROGRAM CONSOLi DATED P C i.M r , , ✓< <br />UNDERGROUND STORA.GL TANK JQ N) <br />CERTMCATION OF INSTALLATION I II/a "1011FICATTON - 4 ZO1Z. <br />.. �. :.(�z form.pergmject).....,...: ..:. , .:.. .. -'• ; � ;.. <br />r <br />r� u <br />�..+., ;..+lR^w•. �7 9:i <br />FACILITY ID '# (Agency Use Otdy) <br />BUSINESS NAME (Same arFacilityName or DBA—Doing Bu v=xA# 3 <br />BUS24ESS'SrrE ADDRESS 103• CITY tom- <br />C�,�`C.`'`j <br />s .. •M. %A w. :. '. .. Wk E . ' '. 4 i '+W:ii:SFfN+MKAtysl'•h .. K`T Av,,., :... Cc . <br />:TYPE OF PROIP,CT (Check an -that atmly) 4131WOi K ::7THORIZ.ED UNDER PF.R:'rIlT 483b, <br />Q 1. TANK INSTALLATION OR REPLACEMENT (Numb •ir Dao°): <br />E] 2- PIPING INSTALLATION ORREPLAcmvIENT. <br />E].:3. SUW INSTALLATION OR REPLACEMENT. $ \ U CJ (s,G <br />:43.4. UNDER DISPENSER CONTAROAENT INSTALLATION OR REPLACEMENT.. <br />SrOTI•IEIt <br />DESCRIPTION OF WORK BEING TIFIED: 483e. <br />EnC ��� ..��:tfc . .. .-V-T e:5� t <br />(&l N DET <br />59 W,WE <br />". <br />..:...:,.,=b+ <br />.1AME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION ° <br />CO)TRACTORUCENSE# 4M ICC'CERTiFICATION#� 1 482` <br />IN WNr <br />I certify that the Information provided herein is. true, accurate, and that the foliowiq c editions have been satisfied: <br />• The-installtr has met the requirements set,forth in 23. CCR §2715; subdivisions (g) anti { i. <br />• The undergroutd .storage tank, any primary .piping, and any secondary containmei was installed according to applicable <br />oi=tary consensus standards and any manufacturer's written installation"ins=ctions. - <br />AII'work listed in the manufacturer's installation::checidist has been completed.: . <br />The installation. has been inspected "and approved'by die local agency; or if required by 1oca1'agency, inspected aril certified <br />are 'stered pro en ' eer having education and enc° with undei trlc ;tots tank' em installations. <br />SIGNA E T O R WNER'S AGENT ' DATE • 1 . - 434.] PHONE . 4s7. . <br />2c�_' ;.2. ' fcar~Cr <br />'S CERTmn,S.TTTLE <br />T _ .._. 4K 4 �� J. .. <br />NAME OF CERTIFIER'S'EMPiAXER (D)BAY aa& CERTUMVS RELATION..F. ? TO TANK'OWNER 439 <br />k 11:. L�:' C �� 1 ' t1�� C � � ; r,t I�'o�il.�R <br />! ; _ LT; 2: TANIt OPERATOR <br />: ` A 3. CONTRACTOR (]. 4. PROPERTY OWNER <br />OTHER AUTHORIZ M: °:GENT OF TANK OWNER <br />... ; <br />.. x : 'IIPCit'UST-C Rev. (1;/2007)'- 1/2 www.nnidocsorg. , <br />