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s Ma!® 23 13 06:44a <br />�►'T l y7Z��nri <br />Elit IV Contactors 12094G.LS342 p.2 <br />!46 <br />UNIFEEDPRoGRAIMCONSOL]DATED <br />UNDERGROUND . . <br />"O')DIFICATION <br />IWAtsb NAME (same - FACMXrY NA&M a DBA - Doimg Dusinm As) <br />i\IANTUA <br />MIMS SITE ADDRESS <br />tobA 05,VmqIE� AXE _ <br />TYPE OF PROJECT (Check I t a <br />© 1. TANK INSTALLATION ORREPLA <br />U 2: PIPING INSTALLATION 92 C <br />—3. SUMP INSTALI AxION C EpLA <br />4- UNDER DISPENSER CONTAItNIAENT INSTALLATION <br />5.OTTER OR REPLACEi41�iNr <br />1 <br />WOR:+. / . THORMD UNDER PERMIT <br />(INum! ei v Date): <br />IS <br />TCS C:.�..c -\its �{=, <br />6 TE�5-LU C<"• ((UMtr. A0F_-•a) TANK'-] N;mu jeR `sipP+c_c {{' <br />u lits RuK.... i.. <br />All Thi i iNu FUf t),5 iv v�<o <br />'� v`'�is a f? .�.�.``� `�i:�.:,iGt:seL�"� K„ � zn i �E t �E � i� ✓ tr w � r n Y a ''ni k ; ,'�,, �..—s 3 <br />� i • �' � A � � . �.i5� e 1 � � .., ..,J..yssW... _ .Y.,���" 5�... .J.aS.w=aF ..t x�,, ..arw-.. .C. .1 .�.. ,« <br />CONTRACTOR LICENSE # <br />66C0,16 ttj l;fi;k.', w2l ICC t Ck Mt,N e; as2� <br />M <br />certify that the information provided herein is,true, .accfaa-ate, and that the following cams tions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivision's (g) and (h;. <br />The _ alnderg. and stoMge..tank, any prin?a?y.. piping, and •an sewn .. containment v <br />71 Y �. installed acc*rding to applicable <br />vo)untary conseasais standards and any aaianufactaarer's written installation instructions. <br />• All work listed in the manufactaarer's installation checklist has been completed. <br />+ <br />The installation has .been inspected and approved bythe.loc <br />1e t Yvfessional' eu io <br />al agency, or if required by .#. e.:'Cal ..agency; Inspected and certified <br />Aeaeer i AYR ediseation and a erience.with underground six l;e tanks <br />'s AGENT stem ipstallations. <br />ZYNiuRE O 0 <br />DATE.. — .aa. ..P <br />NONE 497. <br />lc,- l t� } -`Kc1 <br />CEIYi7k'IER's NAME (print) oas <br />CERT: ER,s TrrLE: ase. <br />TECK <br />NAJviE OF CEi bTI R'S_1f4L.OYER (DBA)4S3 <br />GEItTIFI6IR.'S RELA"Cioxsw `m 1..4NIC OWNER <br />ass: <br />I_ A- TANK OWNER [1 .. TANK OPERATOR <br />3 CONTRACTOR [l PROPERTyOW.NE_R <br />Q OTHIrR YCLT rHORIZED AC I« 1' O 1`AiVK OV✓NER <br />VFCF UST -+C - in <br />Rev. (1212007) <br />