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d Jul 23 12 10: 47a Elit IV Contactors 120946 42 p. 2 <br /> UNIMD PROGRAM CONSOLIDATED J :PRM <br /> UNDERGROUND STORAGE TAI+I{ <br /> CERTMICATION OF WS'FALLAA.TIO r I YODMC.A.TION <br /> y � �� <br /> FACI1.fTY ID#(Agency Use 0WO <br /> BUSINESS NAME(Same as Facaairy Name'or DB.4-.Doing Business,6) _ 3. <br /> i e2 Ln In <br /> liUSINESSS ADDDR,E=SSS tai. CITY. — toa <br /> HA <br /> TON <br /> TYPE OF PROJECT(Check al/Thai aanTv) 4M.1 Wt R aLTTHORIZED UNDER PERMIT .G3b <br /> Q 1.TANK INSTALLATIONORREPLACEMENT: (Tti+.ta orgrDate): <br /> Q 2-PIPING INSTALLATION OR REPLACEMENT - <br /> Q 3.suwjNSTALLATIONORREPTAST <br /> 4:UNDER DWENSER,CONTAngMEN*T D4STALTATION OR'REPLACEMENT <br /> . <br /> 5:O <br /> -- ...._:___.....__. -DESCRnaION-OFSVORKBEING-CER UMD..._----.._._---.__ — <br /> ( !t tC1Sp <br /> Fur)K�T�czl GtT ACC; ve'1 <br /> NAM+E_OF jCONTRACTOnR 4VFi(Or�I'HRFOYR�M�+E-D-AiSTALLATION/MODIFICATION 432& <br /> CONTRACTORLICENSE*6./„/ -j(_ 42c. . <br /> ��s++tLlt�6�.1W�.J 11� ICC'CSRTiFIGATION�`• <br /> a - <br /> 1 certify that the information provided herein is trite,accurate,.and that the foitowinl;i ►Witions have been satisfied: <br /> The installer:has poet th '. encs set forth,in'b CCR§27.15,subdivisions(g)an i .tl. <br /> • : The undergro d storage tank, any primary.piping. and any secondary contaim-e. : was installed according to applicable. <br /> .. vohmtary cone=-standards and-any.nmu#acturces written inscallation'iasttucfions <br /> P All'work listed in the manufacturer's-installation checldisthas'been completed <br /> ® The installation has been_inspected and approved-by the local agency,or°if required')3 tae local agency,inspected and certified <br /> b a' d Professional en eer.ilavk educati m and erience with-under u x ; a tank' stem-installations. <br /> SIGNATURE OF TANK OANER"OR OWNER'S AGENT DATE — .,ra. PHONE '—' ssa. <br /> CERTi ays rind <br /> °� CERTuMW TraE! <br /> �a� <br /> NAME OF TIPPLER'S EMPLOYER(DBA)` °. CEIt1TFTFM'.S REL:ATIOAI1 B 'TO.TANK OWNER ass' <br /> Lt �n Q 1.rANK.OWNER (]'2R"ANK7OPERATOR. <br /> ELF <br /> I CONTRACTOR OR � 4.PROPERTY O WNER <br /> 0:5.OTHERAUTHORIZIM %GENT OF TANK OWNER' <br /> CIPCF LIST—C Rsc•.(,12/2007)—112 www:eaidacx arc . , <br />