Laserfiche WebLink
Sep 16 09 08: 25a Elite TV Contactors 12094616342 p. l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> E — <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID H(Agency Use Only) _ _ t <br /> NV 3. <br /> BUSINESS NAME(Sono as FACILRY NAME or DBA-Doing Business As) <br /> �4 <br /> BUSINESS , 1 tos. CTfY toa. <br /> Q. STALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anoly) 433& WORK AUTHORIZED UNDER PERMIT 437b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number.or Date): <br /> ❑ 2.SUMP INSTALLATION OR REPLAREPLACEMENT <br /> Q �, _ <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT ��JJ <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ <br /> 5.OTHER asx <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> SEP 1 b 2009 <br /> SXN JO?'"i�'l c;ourrri <br /> F;>�P.LI"li�?P,riTo/1Fh7T <br /> III. CONTRACTOR INFORMATION <br /> NAME FONTRACI'OR WHO PERFORMED INSTALLATION/MODIFICATION 432a <br /> 4r-b' ICC CERTIFI TIO Jf 43 � <br /> CONTRACTOR LICENSE f�� I I I�`� - ) � 4( CN <br /> h4 <br /> C IV.CERTIFICATIO`1N' y <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 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 the local agency, inspected and certified <br /> by4egistered profestional engineer having education and ex erience with underground storage,tank system installations. <br /> SIGN OF TANK OR OR OWNER'S AGENT DAT aB1 PHONE 437• <br /> g�3 0 (;Zo? )4eyl- 9Yo/ <br /> a36. <br /> ERTIFIER'S NAS u 493 CERTIFIER'S TITLE: — /- <br /> �.Ly�4 U t fL eG�l <br /> a33 <br /> 489. <br /> NAME OF CERTIFIER' EMPLOY BA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> � T \F� � � {���\TCK—�\ ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> -� `v o J 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(1212007) <br />