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Oct 19 10 12:07p Elite IV Contactors 120946IG342 p-2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One. form.perproject)... . <br />. j. <br />FACILITY ID # (Agent;v Use Only) <br />BUS ome a,4 Fa '!try me or,DBA -Doing B -in= As) <br />103. <br />B INESS SITE ADD S <br />X315a . <br />,!rx .4;;:1.i?x« 'tr.;: xi;,..+x•.5..., s+� +.,.r ._ -•} srw-.w,�.-> z"'.. „_""., a"_°`"WORK AUTHOILIZEDUNDER PERMIT 453b. <br />TYPE OF PROJECT (Chea- all thatazaolvJ <br />E] 1. L'Q <br />1. TANK OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT[1 3. SUW LNISTALLATION OR REPLACEMENT <br />/ <br />❑ 4. UNDER DISPENSERCONTAINMME 7- INSTALLATION OR REPLACEIvEENT <br />5. OTHER 483c... <br />DESCRIPn. '.OF WORK BEING CERTIFIED:. <br />i oxv <br />pu <br />>l�X;Z c�lv 87,5TP <br />0/. 35 <br />1?F <br />Air, <br />Fr P✓r Faw. x r r''rt .� +'r x^ h -,si „aa w,ry -.+i sat <br />N OFA CTOR TERBORMED JNSTALLAMON / MODIFICATION 4 52� <br />ONTRA�I'ORL-i�ENS� � 482b. ICCC� ��'(..� 4s2e. <br />(jUn����•%� � � .ks�.w Ma=wH +4.%(• l �.". � n' yy ..r_"3"S +� Rii Y'it�., _ <br />,, +8r+� .>, ,a - � 1..:-.ra�ax V � �, _.... � f �r3 e r>• <:N ti'n+.a .. rr I�� 'M�r",i� F'. to s.. n' �r `m��'. <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 />voluntary consensus standards and any manufacturer's written installation instructions. <br />All wort: 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 by the Iocal agency, inspected and certified <br />b a registered professional engineer having education and ex enence with undergrotind storage tank system installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484PHONE 457. <br />._ 485 456. <br />CER 'S N9C A5 (print) r- C TITLE: <br />NAME OF E LOYFR (DBA) 4S& CERT IFM'S RELATIONSHIP O. TANK OIt�1ER <ev. <br />❑ I. TANK ovrNER ' ❑ `2: TAiQK'OPERATOR <br />❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />i/LG �v ❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />>rwe.unidoes org <br />UPCF UST -C Rev. (12/200'7) -112 <br />