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Jan 25 11 02: 59p Elite IV Contactors 12094616342 p. l <br /> = ® <br /> UNIFIED PROGRAM CONSOLIDATED FORK( <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MOID -r <br /> ICATIOI�A N 2 52011 <br /> (One form per <br /> r project.) <br /> o . . ., _ .7e, <br /> I. FACILITY INFORMATION <br /> FACILITY(D#(Agency(.Lre Only) <br /> 3. <br /> $IJS S NAME(SA..ac FAC Lrr AP 'or DDA—Duing Business s) <br /> t• <br /> 104. <br /> BUSINESS SITJ-,ADD 103 CITY <br /> cl- q! / ( — <br /> II. INSTALLATION I MODIFICATION.PROJECT DESC: IFTION <br /> °A <br /> ass& WORK AU' B)RIZED UNDER PERMIT <br /> OF PROJECT(Check all that annh) <br /> ❑ L TANK INSTALLATION OR REPLACEMENT (Number or ).te): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT NT <br /> ` lI / <br /> ❑ 4.U MPR DISPENSER CONTINSTALLATION ORA LAMENT INSTALLATION OR REPLACEMENT `J7`'r <br /> OTHER — 4SR <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 1Ida <br /> � <br /> III. CONTRACTOR INFORMATION <br /> NAM CO 1;WOR.Vi RFO 4ED INSTALLATION!MODIFICATION — 482a <br /> 9 'I <br /> TOR LICE S61i TCC CERTIFICATION# <br /> CO 11� ;�� <br /> 6. <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is true,:accurate,and that the following cc iditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR 52715,subdivisions(g)and( ). <br /> • The underground storage tank, any primary piping, and any secondary containmen 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 :he local agency, inspected and certified <br /> by a a' rofessionai en ineer having education and enc erience with under rounc Stora a tanks stem installations. <br /> SIGN �OTANKO �§ AGENI' D�(' osa. PRUNE 7497• <br /> ass CERT R'S TITLE: 4s6. <br /> CERTIFIERS AME(print) <br /> ( J. <br /> NAME OFCER'rIFtE 1S EMPLOYER( ase CER:rif-IER'SRELATIONSI 'TO TX NK OWNER 489 <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> S.OTHER AUTHOR12:1- ;kGENT OF TANK OWNER <br /> UP'CF UST-C-lh Rev.(1212007) <br />