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Jul 24 13 06: 39a Elite IV Contactors 12094616342 p. l <br /> F JED <br /> UNIFIED PROGRAM CONSOLIDATED FOR 11• <br /> UNDERGROUND STORAGE TANK Ck I RON M ENl. L <br /> CERTIFICATION OF INSTALLATION/MO] �IFICATLTH DEaARTMEN <br /> e tbrm per project} <br /> IfRK <br /> am <br /> T '. 1V '4tlr'iCA�'Lt7lf;ry <br /> FACILITY ID 4(Agency Use Only) <br /> r <br /> UTO J1 <br /> BUSINESS (S�me u EACQ.ITY N ar DB - Ding Buvness As) 3. <br /> BUSINESS SITE ADDRESSll 103. CIT 104. <br /> P5 [0a jul L'� AGS. e ]krn <br /> Ll ,1NSTALLA.TJO7\ !M IF.. : ✓r1_.L^..JL L <br /> t3J :!kBJ ATION PRMON <br /> TYPE OF PROJECT(Check all that aooly) 433 WORK AU AORIZED UNTDER PERI 11T 4836 <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number of )ate): ); <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT / <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT Cl C7 c jai <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4sx <br /> �s'7 ST 1�rin y tj�t'u: a�� n,�;�'?arL n i. J�� <br /> �j — S1 G et_ <br /> Ci.�'L' ✓�•�' ����?Cl,�.�-TSV J...�! - �! ...... _.._...-.._... <br /> IIL !f.TRACT01+~y$1 4R14ATION <br /> NAME OF CONTRA WHO E bRM> QSTAL ON/ ODIFICA ON <br /> /I <br /> J. <br /> CONTRACfQR LICENSE# / ICC CERTIFICATION,# 482e. <br /> I certify that the information provided herein is true,accurate,and that the following con .itions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(Ii) <br /> • The underground storage tank, any primary piping, and any secondary containmen: -as installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work 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& local agency,inspected and certified <br /> re istered professional engineer having education and a erience with underground st rage tanks stem installations. <br /> IGNATURB O N� 'S AGENT ® DAIFE PHONE W. <br /> CERTIFIER'S.NN ME(print) 495 TIFIE TITLE: (� 496. <br /> -j[d i'0 f �4Lt� ,(t;�t 'til'•� f► tG+ (��f iC.� <br /> NAME OF TIF ,S EMPLO B j 488 CERTIFIER'S RELATIONSHIP 0 TANK O abs'T . <br /> 7 7 / ❑ L TANK OWNER ) 2.TANK OPERATOR <br /> jr <br /> p� �� �� �'3.CONTRACTOR 1 4.PROPERTY OWNER <br /> fr' ❑ 5.OTHER AUTHORIZED A ENT OF TANK OWNER <br /> UPC'F OST`O-12 Rev.(12/2007) <br />