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May 05 11 11:42a Elite IV Contactors 12094616342 - _p.1 <br />UNIFIED PROGRAM C0NS0LI _- F Mi'M <br />i7ND RGROLI`M STi OPUGE TAMK dam' �d <br />:.(Qne form-perproJect}.. <br />ON <br />., :. :•e.,r�� ��p. . � 1i1+XS :�ta-xur. , s9a. ,2?�°�'sk '+ �+a�'�td <br />FACMn Y ID P (4ency Use Only) --' <br />BUS NAME(Sanr�rsF 7ity ameorAB.a-Doing <br />Badnas&) " 3. <br />BUSWESSS ADD 703. 104. <br />- e <br />TYPE OF PROJECT (Chwkall9=any- lvl 45- WO's 1'7TFIOR= UNnr=R PERMITh 4s3e. . <br />. I. TANK DiSTALLATIONOR REPLACEMENT:(19ni nl ? cor Dafejr <br />El2.PIPINGINSTALLAdON-ORREPLACEMENT. . <br />0...3. SIW INSTALLATION OR REPLACEMENT ' <br />4. UNDER DISPENSER-CONTAItQMENT INSTALLATION OR REPLACEMENT. <br />.TER : <br />ESCRIPTIONAF-WARK33EAJG•CERT.iF�D:_--------------..____._,.�,_._._f:_,..._.._,�---.-.:...V..- <br />Ire' <br />�,�y <br />L4AA1E OF C0 ST TIOb' /MODIFICATION - _ 4M <br />CORIRACTOR CEASE# ��' ICC'CERTIFmCATION'# 482c. <br />• <br />• _ l..S. _ av:e:2 <br />Y certify that the iniformation;provided herein is.true, accurate, and that the foliuwing co ditions have been satisfied: <br />Me installer.-has-mei thu=quh°ements set fort4,in 23 CCR '§ 2715;:subdivW6ns (g) anci <br />.. The underground storage tank, any primarypiping;'and any secomarycontaimmat a•as installed according to applicable <br />- - -voluntary. consensus=standards andany..uianixtacturer's uriiCen instaliation=inskuctions: - <br />.A.11 work fisted in the manufa�s•installation chedcCist'has'becncompleted •- <br />•. <br />The, installation has been .inspected and approved:'by the local agency, or if regiure3 .b'.t local agency, inspected and certified <br />by a • professional en " eer. hai ing education and experience withunc:.s )rade tank stern installations. <br />SIGr OF TANK OWNER: OR' OWNER'S ACENT` .. ' 'DATE - 414. ' PHONE. • - <br />. 11 r�I�l <br />MER NAMZ (Pj. _..CERTIFIER' - <br />' � : 68i <br />NAME OF CAITEMIS EMP I'ER (ABA}'' 49L,. 'CERTIMER'S M AVONSHtP i�,T.Qa OWN£R 4e9. . <br />4: MAN K1 OWNER'-''2'TfNK'OPERATOR <br />-3..CONMACTOK : ] 4. PROPERTY OWNER <br />�.�5.'OHEt:4UTHORIEA ENT OF TA <br />NK OWNER' <br />.. " UPCF:.UST-C Rmm (1Z`l = Ia <br />