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Ruga28 13 09: 49a Elit IV Contactors 12094 6342 p. 2 <br /> RECEF LD <br /> uNmnmrcis ATEi� . <br /> iMERGIROUM STOJRAGE TAMC 2 <br /> CERTr.FICATION OF IN8TALLATIC?N/t4 aODZFXC <br /> N . <br /> FACILITY ID#(,tency Use 0+1!51 r <br /> BUSINES$NAME(S%=mFACXM aDgA 1 n�9usia�sAs? <br /> BUSIMM SITE104, <br /> ADDRESS 103. Crr3t _ <br /> TYPE OF PROJECT(Cf1C4&A 1&9a 1 .421LWOn K .UTII®RI7ED YINDSR <br /> Q I-TANK MTALLATTON OR REPLACEMENT; FERhlrr 463 <br /> .2 PIPING INSTALLAITON OR REPT.ACT Chun ib or bate): -v <br /> 'D 3.SUMP INSTALLATION OWREPLACI QNT � <br /> Q 4.UNDERDISPENSER CC)NTAINMENT•IId TALLATION ORREPLAC:EMIENT `✓(��, 'y c (` <br /> 5.OTHBR c k t J <br /> D .CRII'TION OF WORKBEING CER - .- , <br /> 4830 <br /> ' tram i ic' � <br /> Lim tk. - <br /> ' <br /> NAME OF CONTRACTOR WIiO PERFORMED INSTALLATION I MODIFICATION' <br /> 4621 <br /> COMMACTOR lZME# • 492aICC CERTIFICATION# - 463a <br /> • <br /> Ice <br /> �.. rtify-thad-thei�ko�'ma�ion-prowided-herein•istrae;aceirrste;and•�,Trat•tlie-fflIlowineg-a:si l.itlons-have-'been-satisfied:_...:____:__.-__._: <br /> '....Zh .installerhas)nct.t}Ie..requirements.setforth..in..23-CCR- 2XIS,sr�hdivvisions(g)and(i) V <br /> talc g <br /> e <br /> ® The.underground storage tank, aiiy P ?? '.:•piPhI& .may. secondary'Cdintalaunelt t ras ins ed accordin to <br /> vo untary consensus stare aaY amu.._ .... .s wntten ns... .atron applicable <br /> instructions. i <br /> • ' A.tl vroirlc tisted'in the mantifecturec's u)s�I'Iadozi chistliasl;een eon3plefed, ' .. r <br /> • . :Ttt installation has,.been-inspected and approved by'tfie Iocai <br /> agency, <br /> b arifrequired by d :local agency,inspected and certified j <br /> istered rolfessional.en ' eerhav' educationand a `suce wrtEr unde and st r2.a tank stem iQstailations. d <br /> SIG 0. T AROWNER.'aAGENT- - 4 <br /> D�TE.. <br /> _ .- <br /> PHONB- _.... _ ,. . <br /> tp�ty 4:s <br /> •cERTIFI�R's TITLE:,Y. � 4K <br /> • PIAME aE�TIFIER's ErvsPLoi�It t�gA� . .... ' _ <br /> r- . � r.• `,-. ° Cl?R'l71)IEk2.'S"RELATION III:�: .)TANS CWNEIt..... . � <br /> t.-ti �` C J I C I` P C.I� j (L•f f�, ?' Q I.TANK OWNEIR• .'' [ .2.TAW 6P.ERATOR <br /> 3.C;OI+ITRACTOR L 4.PkOPERTYb6YNER <br /> OTHER A�► iQi{IbD.:LC -NT OF TAMC OWNER <br /> - <br /> •• Rev,(1212007) <br />