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'` Dec '19 13 11 : 27a Elit IV Contactors 120946 342 p. 2 <br /> RECEivE <br /> r. <br /> a <br /> UNIFrED PROD .CONSOLIDATED F )IRM 1 <br /> UNDERGROUND STORAGE TA1Ni< <br /> CER CATION.4F INSTALLATION/h :ODM <br /> _(One,form,perproJegt). l <br /> �4 <br /> H DEP RTMENT <br /> FA CII ITY IA#(APWY use onf <br /> Y) <br /> BUSINESS NAt� •' <br /> (Same as FeczlftyName or DBA-Dofrtg BusfrressAsJ 3 . <br /> BUSINESS ITE 103• CITY <br /> CnA <br /> " Safi .. '�%if•.h': -.. <br /> TYPE OF PROJECT(CheckRlt That analvi 48a� W03 K ?UTHORiZED UNDER PERMIT <br /> [� 1.TANK INSTALLATION OR REPLACEMENT: WO tX r U HCR <br /> Q 2 PIPING INSTALLATION OR REPLACEMENT. <br /> �.3.SUMP INSTALLATION OR REPLACEMENT �� �t <br /> Q 4.UNDER DISPENSER CO A1NA2ENT INSTALLATION OR REPLACEMENT <br /> 0-5.OTHER• �. �: ('.c i� t. <br /> DESCRIPTION OF WORK BEA1 — <br /> 40L <br /> �—i11 �a���7 • <br /> T:cb�,r) ��i <br /> _' . <br /> NAA9&OFCONTRAcn I"WHOPERFORATEDiNSTAiLATIONlA9oDIFICArdoN. <br /> COATRACTORL'CENSE#. ( �� j� affin. <br /> t 1 11J.�� CC31 A.b`,_,��l.' C f(�Z JCC CERTIFICATION# 7asap <br /> I certify fleet the laformation provided herein is true,accurate,and that the following .c 71)m1m <br /> ve been satisfied:' <br /> •; The installer has met the requirements set forth in 23 CCR§2715;subdivisions(g)and(k v 10 iul d o d storage tankany.primary piping, and.any secondary conte inm�:�t ed according to applicable <br /> tart consensus statadards_and any-manufactumr's written installation instructions: <br /> • All work listed in the manufacturer's,instanatioa checklist has been completed. <br /> • The.installation.has been inspected and approved by the local agency,or if d b,.t ;e Iocai a <br /> agency,inspected and certified <br /> bare 'stered 1ofessional ha education and enee with and unsl f . e tank stem installations. <br /> SIGMA . FT O R WNER'S AGENT DATE` '' 6 f — 484: PHONE asr.. <br /> CER R'S (Punt) �2d k!. 653,91 <br /> 485. CERTYF'm'S.TT _a- 485. <br /> NA tME¢01 CERj T�I(FIER(G'SEMPLOYER(DBA) <br /> (DBA) ° CER7TMER'S RM ATIONSH IP '0 TANK OWNER 489. <br /> (CtC..1 t 4 L�.I.TANK OWNER 2 TANK OPERATOR <br /> a 3.CONTRACTOR': 'J'4.PROPERTY OWNER <br /> S.OTHl RR AUTHOR1ZW A 'ENT OF TAMC OVrkmD <br /> a' UPCF UST-C Rev.(12noo7)=!12 <br /> wwwxnidomarg <br /> • i <br />