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Jul 08 09 10:58a Elite 7- Contractors Inc 20946163f2DLP-:I <br />' <br />UNIMED PROGRAM CONSOLIDATI"D FORM <br />UNDERGROUND STORAGE TANK SAN J('- <br />)UNIF,' <br />CERTIFICATION OF INSTALLATION/ MODIF1CAft6N­ -TAL <br />I <br />HEAD',,, fl..� C','MEN <br />(One forin pcir pro <br />ject), <br />-A <br />I i;ACILrJY ID urewv Use rivir) I I I T <br />NAME (Same as Fa6n'v Naar or DIM - <br />BVSLNM SITE ADDIWSS <br />ra <br />1N ICA -110.N PR 1J UP JON <br />il. CA <br />TYPE OF PROJECT (Chrck aLLhat.,0r!h,) Tr�7, W ORK ALM-rOR UNDER PERMrr 493b. <br />I <br />[-TANK INSTALLATIONIORRF-PL&CEWNT (Number or Dift): <br />Z PIPING INSTAILK110N OR REPLACEMENT <br />F1 3. SUMP INSTAIJAPON OR RUPLAZEMENT <br />❑ WW <br />4. UNDC-R DISPENSER CON`fAINMnNT INSTALLATION OR RF.1'jA(7FMFNT <br />S nTfzpk /W . - I <br />4160 <br />1111'�la,k ..S_crtsat 'W C13?6 1 <br />1 s l I Ci11,cc�e�l�l �e n� �d11�� (11' �, at( ULtld <br />NAME OF CONTRACTOR POWDRMIM, INSTALLATION MODIFICATION 4VU <br />If L* C I L) <br />CONTRACTOR 14C04sl: )CC 05KYMCATION <br />X59 n <br />Lf <br />I certify that the information provided herein is true, accurate, and that the following conditions have been SaltiSrICd: <br />The installer has mot the requirements set iorth in 23 CCR §2715, subdivisions (g) and (h)- <br />• T11e underground swrjgc tank, any Primary piping, and any secondary containment was instaBcd according to applicable <br />voluntary consensus standards- and any manufacturer s written install;rtion. imstructions. <br />a All work listed in the manufacturer's installation checklist has been completed. <br />V <br />The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a rcF'stored profmional engineer havinZ, education and ex ence with under "und.gtorage tankrystern installations. <br />SIGNAT . F TANK OWNEK OR OWNER'S AGEWI' TE "4- Z1)A 1 PHONE C1i2 t1 It'S NAME <br />_- I " In C <br />(P"4n.s. 0:�R77TER'S..nTLZ 4M. <br />pr4ialj . & t- lu'a I e� 6 /' I � Ik; 1-7 <br />rA"Dr, C6';LTIFMR'S FWLOYER (DBA) CERTTFrEws xet.KnoNsiiv, TO TANK OWNER <br />0 1. TANK OWNER M - 2. TANK"OPERATOR. <br />LY, Wt 3. CONTRACTOR El 4. PROPERTY OWNER <br />M 5. OTHER AurHom r7ym AGENT OF TANK owNj-.-jt <br />tTPCF UST -C Rev. (12MR17) -112 WWw.0qi4IPCSArN <br />