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Nov 18 10 09: 06a Elite TV Contactors 12094616342 �'" ��"� P. 1 '® <br /> UN1FlEDPROGRAM.COh*SOIGZDAIEDFORM Z ,fir <br /> UNDERGROUND STORAGE TANK <br /> CERTMCATION OF INSTALLATION MOD <br /> (Dcie.fonn-p projeg0.:._._. ..._ <br /> . - z <br /> r, <br /> ,... ::::. . --.. niL...,," .,,.:.: t•a,xe.�w'.n .�u' . .. .. s0.'�.s`w'w�•s-u^a�s�" r,��e°':'����� "' 'u" .�y <br /> FACII=MI(Agency Use Only) .... <br /> B[} S NAME rww as A d ifyNmxc or DBA—Doing. ,�dn s. <br /> : <br /> BUS IN SSMADDRESS rat. . <br /> CITY ,�. <br /> •;.,Tm OF PROXEGT:(Chwk"a�hat am7Iv1 '" . .WORKAUTHORIZED.UNIaER PEt;MlT es3n. <br /> Q.L TANK INSTALL:ATTQNOR REPL ACSVM4T: (Nu¢tbtx or DateJ: <br /> 0 2.PTPINGINSI'ALLA7ION-ORREPLACMh�m-r. <br /> 0..3:SE&e INSTALLATIOAT OR REPLA' EMENr. <br /> ... :❑.4:UAIDER DISPENSEIt,'COATAINMENI'IIiSTALLATION ORREPIa4CEM&hT . <br /> lt�� t+Kl� Csr'1{f f, '� (J fT: <br /> N F CO CrOR.W90 PEUO Kgyp IA'ST ION./MOD CATION.. <ex <br /> NTRACTOR • E#. _. ICC'CERTTFZCATIOA'# aszc <br /> I.certify that"the infiormalion proBlided herein is.true,.aceurate,and that"flie folibwing,coieditions.h2ve been satisfied: <br /> .Tlte'installerIss'met the- gpirmnentr set forth.in 23 CCR'§27.ZS;:subdivisions(g) <br /> The' tmdergrouad:Storage.-tank, any PnmarS'.P?Pa►S;"and..any secondary coniaiimaeni; as installed according to <br /> applicable" <br /> votuutaq consensus standards-and arly,manuhcft is avcitten iustat3a nahuctioz_zs <br /> .All work listed m the inanufabtvrees•iuswjation cheddistlzas been-66 feted•. <br /> • . <br /> The iustatZaiion:bas.been:ft spepted and approved'by the.local"a Cne;','orif regim+ed'.hy the local agency,inspected and certified <br /> ac -and cih'ud d.strah nfea oge tank em installations. <br /> SIGXA 9F,Tr OWNER OR-OWNER'S AGENT :DATE.'.. °Bq• PHONE <br /> 'S NAME axs. aas <br /> 'NAMED 'S YER A) CER R'S:REt:9TIONSEIP.TO,TAI*MOWNER <br /> .: "`.\�����►-•J ..:•-�"I. -O.tSR?ER...". .. 'OPERAT08 <br /> ".' •..Q 3.COi,"1Rrt.GTOR:.:...: .. Q;4-PROPERTY OWNER <br /> IS CIL-3 'AGENT OF TALI:OWNER <br /> ^•c? MICF:)ST-=C P—m(I2/3007 i/S`. <br /> - ... warK:ani ocs.ora <br />