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Dec 01 08 01 : 38P Elite XV Contractors Inc 2094G1G342 p. 3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> L FACILITY.INFORMATION <br /> FACILITY ID#(A&"cy U.ec UM(V) <br /> BIJSINF.SS Snore as!%acif_ 'erne nc AR -flnft Bu, Hess Aa) � �• <br /> BUSINFSS S •AI Itl•:5 /� / u3. 1C1TY 11id• <br /> _ IL.TNSTALLATION'/.MOD1lFICATION PROJECT DI+~SCRIPTION . <br /> TYPE OF PROJF.C.I'(Cficckall rhar un�,Rd <br /> 411 WORK AU7IIORIZED UNMR 1111ltMIT °xtit' <br /> ❑ I.I'ANK INSTALLATION Olt ILLI LAG'LiMLNT (Number or Date): <br /> ❑ -1•PIPING INSTALLATION OR RT.•,TLACEMLNT <br /> ❑�!STJM)'rNSTALLATION OR REPLACEMEM' <br /> 4 RR DISI'1:NSER CONTAINMENT LNSTALLATION OR REPLACEMEA I <br /> OTHER _ <br /> DESCRIYT]ON OF WORK 141NG CUUIFLED: �xk <br /> U/ <br /> ALA, <br /> r C /VL <br /> 3' PKI <br /> ~JIL CO OR <br /> . : . . . ' INFORMATION <br /> NAME OF CONTRACT OR O 9 :D INST JO DIFI ' TION <br /> CONTRACTOR LI Z,1;1! °x71r' 1CC'CERTIFICATION# <br /> r <br /> IV. CERTIFICATT0N <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> volunWry consensus standards and any manufacturer's written installation irotnlctions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the focal agency,or if required by the local agency, inspected and certified <br /> by a ie,'stered profes.gional engineer having education and experience with underground storage tanksystern installations. <br /> SIGNATURE TANK OWNER OR OWNER'S AGENT DATE AM.j PHONE 49'7. <br /> CE117 fER'S NA nnt) f J <br /> °NS' C1 R T1L 'ITTLE 9A. <br /> ✓ 62/ , <br /> NAML Ol,CEI011;LZR'S EMPI,OYLiR(DBA) °xx' CF.RTTF'IF.R'S RELATIONSHIP TO TANK OWNER M. <br /> �I © I.TANK OWNLiR ❑ 2.TANK OPERATOR <br /> �] /j�/�� ❑ <br /> 3.CONTRACTOR C1 4.PROPERTY OWNRI( <br /> s.o7i-i R Al,1TROQU-1)AGLN!'U['"TANK OWNLR <br /> UPCF UST-C Rev,(1=0".112 www.unidtws.org <br />