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- Aug 11 11 08: 13a Elite IV Contactors 12094616342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED P( ICM <br /> UNDERGROUND STORAGE TAM,'. <br /> CERTIFICATION OF INSTALLATION/.'V <br /> (IDIEICATION <br /> (One form per project). <br /> r� ii rJ^^'pw�7� r +x xr•a. r'.* aT "�`"'� g. ,x. ..x a r w'rsxrir .n :.r -c <br /> x 'r�'�} <br /> �."-x..: bra.nX'�F •z .�jv w� rfi'�.��•:^i "�{ ..��yi� SJR �i i_ <br /> WI; <br /> R�.Vl.Ax"�Z�Q �. <br /> FACILITY ID#(Agency Use Only) <br /> 4� <br /> BUSINESS NAME(Same as Fardiry Namea,DBA—Doing Business As) 3• <br /> BUSINESS SITE ADDRESS 103• CITY — 104. <br /> .: » <br /> 3< 7` II 3TSZ4LLA�I+�N1VIODIFICA3'I01'dR�C3 {;'7 oESCRLPTiO�'!T <br /> TYPE OF PROJECT(Check all that apalvJ 483, WOI•,P, �.11MORIZED UNDER PERMIT 493b. <br /> ❑ 1-TANK INSTALLATION OR REPLACEM a, (Nu_nt r or Data): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3-SUMP INSTALLATION OR REPLACEMENT <br /> Q 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER _ <br /> DESCRPTION OF WORK BEING CERTIFIED: 493c. <br /> �nt�1 STF1��C �l vsct (C"10 Utpff T"�, (30 5 n -11k�EZ0 4 -L I:�U(,_C�1 <br /> CV 30 •cpm T6 <br /> "@16rj) CWiI1 �e � ' a Inx_fi e� <br /> � <br /> .rte E.�, a•�`' .y a ':na yry 7�'�r�-�'•,{`...�1c�+rt�}.•q�.� <br /> .3,^?,•-'•:,-v.r.t, y;' X31'.GL'x'..h" ,?•''f <br /> ANN <br /> a r -:L.''0,4�I:�IkI\t13.i.1 .11 �Y �1.:1' �.: M 4.•_, �T �a�M1�y j .`•^i 7': F L.£ _ <br /> .. x...,. ... ..... J,..''--. .'�:': w.M... ...a..-.,.c. w,..:. raay.e x,15.....,,.... s n .__�.�•.�., l.�. ...•7, ,•flx'. .�..,.4'•'� ,t+:� �.; a_j._ r. <br /> NAME OF COh"TRACTOR @PHO PERFORMED INSTALLATION/MODIFICATION 4s s <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION li <br /> �S7tJ:�U�U2 482c <br /> KX -Ai39 <br /> w mss; Gni 8. Ifl1�T � <br /> b <br /> �Y�.'� <br /> I certify that the information provided herein is true,accurate,and that the followinll c luditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)anti <br /> • The underground storage tank, any primary piping, and any secondary containul,-1 'alas installed according to applicable <br /> voluntary consensus standards and any manufacturer's Written installation instruction:: <br /> • All work listed in the manufacturm,,installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or if required:'y 112 Iocal agency, inspected and certified <br /> by a registered iyofessional en •FA�GENT <br /> having n448S. <br /> nce with underground ,corage tank stem installations. <br /> SIGNA T W71t O OTE 490• PHONE 497. <br /> TER'S NAME(print) RTIFIER'S.T1Ti E: 4aG• <br /> 1NAME OF CERTIFIER'S EMPLOYER(DRTIFIER'SRELATIONSK IOTANKOWNER 439. <br /> I.TANK OWNER2.TANK"OPERATOR <br /> CONTRACTOR l_] 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED ,:;ENT OF TANK OWNER <br /> UPCF UST-C Rev.(nno"-1/2 www.unidocs.org <br />