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jar 30 12 12:17p <br />� s <br />na <br />Elite IV Contactors 12094616342 <br />p.2 <br />rfNIl�'IEIS"PKQ'mmS0'WAT'ED'F ft 4i' <br />UNDERGROUND STORAGE TAN]I; <br />CERTIFICATION OF INSTALLATION / :1! iTDIIFICATION <br />IM nil <br />.. , r�.r �. form per project) <br />(One <br />• FACII.ITY ID # (Agency Use 0171y) <br />nAhM'0rZMA — DoiatBuzid= As) <br />l�J 'Ct i� ALL <br />BUSMSS SITE �40DRLcSS <br />5T6 C -M-1 <br />TYPE OF PROJECT (C6eck aimx'' <br />❑ 1. TANK INSTALLAITON OR REPLACEMENT <br />❑ .2 PIPING INSTALLATION OR REPLACEIll <br />3. SUMP INSTALLATION OR REPLACEMENT <br />] 4.OTRMZ CONTAINMENT <br />DISPENSER <br />71 S. OTHER INSTALLATION OR REPLACEMENT <br />ltr- <br />�ln��tim� ; but <br />- _, <br />NAME OF CONTRACTOR WHO PERFORIviED D <br />l= L, TF TV' - '1� <br />CONTRACTOR LICENSE # ' <br />ICC CERTIFICATION # <br />VIM <br />MMMMM- <br />aa:.. <br />tQb. <br />---------- .� ••••�, .a�u�a�r, ava-�naL uze Iotlowing coird Tons-have-been-satisfied-dcab <br />The installerhasmettherequirements set forth..in-23-CCR §2715; subdivisions (g) and (h)ha underground storage tank, ally primary..pivo untary cons=ussian y p and.any secondary 'containment w insia[led according to. aan an mane er. s wntten anon mstrud fns. _'A(I .work listed in the manufacturer's installation checklist has been. completed, <br />Th installation has beeninspectedand approved by'the local agency, orif required the:al a enc istered rofessionalen ihavin education and a enence with under and stc>r. ,e tankO'm g s te.pecte andiizstallatians <br />NE_ ae� <br />� `. X71` <br />IER'SN :{prim) its CER — ! 26 . t <br />TIFIER'S IT I'LE. <br />NAMis OF CEI2TIFIBR'S'EMpLOXER (b$A) <br />CERTIFIR'S RELATIONSHIP 7' E�NIC OWNEEi <br />TUB K�CG L TANKOWNER• '' C.: TAM OPERATOR i <br />. C1 3. CONTRACTOR [ t I'ROP <br />ERTX OWNER <br />❑ S. OTiIER ATJT$OR AGl ih :OF TANIC.OWNE& p <br />