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E <br />I <br />Elite IV Contactors 120946163 <br />M <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION 1 MODIFI-fRAT1,10 9 <br />/V <br />(One fbrm,perpTqject)..... I -IPA, cnl,. <br />BUSINESS SITE RES X03. CITY <br />TYPE OF PROJECT (Check all dot 4E3a <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />[1 I. TANK INSTALLATION OR REPLACEMENT <br />(Number or Daft): <br />0 2- PIPING INSTALLATION OR REPLACEMENT <br />El 3. SUMP INSTALLATION OR REPLACEMENT <br />0 4, UNDER DISPENSER CONTAINMENT rNsTALLATioN OR REPLACEMENT <br />7 ol <br />0 5. OTBER <br />/SF <br />4 <br />493� <br />R <br />DESCREMON Of WORK BEING CER <br />CJ <br />e K <br />7 ocav <br />1(j)// Wi, L Atop& -i�' <br />M E 4D <br />rOR TION MODIFICATION 4W4. <br />IRS <br />A IL <br />NAIrTTAL <br />4M 4M. <br />04110ENS9# ICC CER 0 # <br />jo &AZ 'Mel —(t <br />a.+� 5 �T-X: 75 1 <br />Pill <br />IN4 <br />I certify that the information provided herein is true, accurate, and that the followingo 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 />bya"i �tered professional engineer hELnZ education and experience with and and storage tank system installations. <br />tkIGNA7U"TANK OWNER OR OWNER'S AGENT <br />7 4", <br />PHONE <br />L <br />41 <br />C 'S NAME (p�) 48S. <br />j Dar I k.. i <br />VIE•R-S T=: 486. <br />N6W OF 488 . <br />IFIER'S EMPLOYER (DBA) <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />0 I. TANK -ORNER- E3 ITANKOPERATOR <br />C1 3. CONTRACTOR 4. PROPERTY OWNER <br />AUTHORIZED AGENT OF TANK OWNER <br />5. OTHER <br />UFCF TJST-C Rev. (12r-007) -1/2 <br />www.unidocs.org <br />