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Apr 25 13 12:04p Elite IV Contactors 12094616342 <br />•UNrFIDED PROGRAM CONSOLIDATE. D T ORM <br />ERGROUND STORAGE TAX . <br />CERTEFICATION OF INSTALLATION / MOD CATTON <br />(Agency <br />wme = racat:ty Name orr DHA —Doing Business As) <br />KESSCie <br />u�y7��ry� 343. <br />P.2 <br />TYPE OF PROJECT (Checkal{ thax atmlvl SAO I AU rHORIZED UNDER PEpj,= <br />Ci I. TANK INSTALLAT70N OR REPLACEMENT • (ldu dyer oc Date): . <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT. <br />[] 3. SUMP INSTALLATION QR REPI.AC$MEN f,� <br />L� 4. UNDER DISPENSER CONTADR,4ENT INSTALLATION OR REPLACEMENT <br />j�, 5. OTHER <br />DESCRIPTION OF <br />WORK <br />1 e «..._T_ �.,i� � t 1i1�. �'�,�. 14.J iJc..i�� JAN �I V) �'T�4V ® ,.n• I�- <br />� <br />CONTRACTOR LICENSE # . - aim. _ .. <br />ICC CERTIFICATIOA' A aaz, <br />(j. <br />I certify that the information provided herein is tate, accurate, and that the followiiij conditions have been satisfied: <br />® The installer has met the requirements set forth in 23 CCR2715 subdivisions <br />• The rrnde § n (g) ani <br />rground storage .tank; any primary Piping, and any secondary containcp !nt: was installed according to applicable <br />voluntary consensus standards and anymanufacturer's written installation inskuctio:zs <br />•. <br />All work listed in the manufacturer's installation checklist has been completed <br />• The installatioa.has btien inspected and approved by the local agency, or if require.', I .i the Iocal agency, inspected and certified <br />b a re 'stered mfessional en 'neer ha education and a hence with and rn 9 store tank stems instillations. <br />SIGNA F TAN Q R WNER'S AGENT DATE PHONE asp. <br />CER R'S N CERTIFz Itis rrlx : --r (1 L _- 48C <br />NAME OF /CERTIFIER'S EMPLOYER (DBA) { ase CERTIFIERIs RELATIOI4, [fP TO TANK OWNER 689. <br />C �V `5 . I..TANk OWNER : E] 2. TANK "OPFA A.TOR <br />[a 3. CONTRACTOR. . ❑ 4. PROPERTY OWNER <br />D 1�. OTHER AUTHORI U s AGENT OF TANK OWNER <br />UPCF UST -C Rev. wwW.anidocs ®z g <br />