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Deo 29 08 10: 56a Elite Contractors Ino 209461 - 42 P. 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM , <br /> UNDERGROUND STORAGE,TANK <br /> CERTIFICATION OF INSTALLATION !MODIFICATION <br /> (One form per project) <br /> I: (FACILITY INFORMATION <br /> FACILITY 11.)It(Ag w v Use ady) <br /> BUSINF.S$ AMF(Same as haerliry Name or DBA-Dolnr BustoFes Aa) <br /> BUSINLSS SITE ADDRESS / i ra)• CiTY 104• <br /> o . , <br /> <�_•. ��. r�' %ii/%':'•/ ._...: <br /> 11. INSTALLATION� OAIFICA►TIONTROJECT-AJESCRIPTION <br /> TYPE OF PROJF.(4t'(Ckecka)jjhatornlr,) °xk WORK AUTHOR17FD UNDER PERMIT <br /> ❑ I.TANK INSTALLATION OR RF1'LAcrrm rNT (Number or Dwc): <br /> ❑ 2.1'IPING INSTALLATION OR RrPLACEIAEiNT <br /> ❑ 3.SUM('INSTALLATION OR RF.MCAC.M.1?Trl' <br /> a4.UNDFR Dtsri.NSER CONTAINMENT INSTALLATION OK IUXLAC1iMLNT <br /> El 5.OTHER <br /> QFSCRIPT ON ON WORK BEING CERTIFIED: 4xx. <br /> ,,-�- <br /> )/ �,;.; f f.'./\1 I �:•�: /i y is' :�.. /:r <br /> dr <br /> .I <br /> _ III: CONTRACTOR INFORMATION <br /> NAME OI'CONTRACI'OIc%kho:PNU 141IN$TAir' TIO '/M01)IUIC'A'1lUN /j' 4xv <br /> CONTRACT'OR LICENSE# " 4 ICC CL ICrIF1CATION# <br /> N: CERTIFICATTON <br /> " <br /> 1 certify that the information provided herein is true,accurate,and that the following conditions have been s2tie6ed: <br /> ® The installer has met the requirements set forth in 23 CCR X2715,subdivisions(g)and(h). <br /> ® <br /> The underground storage tank, any primary piping, Lind any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instluctionS. <br /> All work listed in the manuflcturcr'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, inspceted and certified <br /> by 2yegistered prorcssional engineer having education and ex ricncc with under Round storage:tank system instal lations. <br /> SIGMA -OF TANK OWNER OR OWNER'S AGENT VAYE PHONE ""' <br /> lo K <br /> P fAR'S NANII rind 49CS.(n 4xn) Clilt"tTF STITLE, • <br /> is f <br /> NAME OF CEICt F'UR'S EMP)rOvr.R(D13A) `"g CERTIFrrFt'S U-1,ATIONSIIII'TOT 'i.OWNLR <br /> ❑ I.TANK OWNER .TANK OFBRATOR <br /> J' ! ❑ 3.CON''TRACTOR Q 4.PROPERTY OWNER <br /> _.r // ✓'1 ✓ J !( '/l /l i `:' / Q .()THI K AUTHORIZED AGU INU OF TANK OWNER <br /> Ue'CV USI'-C Rev.(12/2007)-1/2 www.unidomorR <br />