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Feb 01 08 12:34p <br />Elite Iv Contractors Inc <br />0 <br />2094GIG342 p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK FEB 0 12008 <br />CERTIFICATION OF INSTALLATION MODIFICATJ.QN <br />(One form per project) QUI COUNTY <br />REALTH <br />1. FACILITY. INFORMATION... FEPARP�WENT <br />FACILITY ID # (.4gemZv Use Only) <br />t. <br />BUSINESS NAME (Sames f�,iliry Name or DBA bD sines.8, AS) 37 <br />7,x u <br />ok ) <br />BUSINESS SITE D SS 103. CITY V 104. <br />INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that avaty 483a. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />WORK AUTHORIZED UNDER PERMIT 483h. <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />W673 I L/ <br />0 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 48R. <br />99 -�2666 6Z, 2 <br />)qlV <br />t /I <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION —482a. <br />I <br />Cli �e- V C <br />. r, 4 <br />CONTRACTOR LICENSE # 482b <br />6 2 2 0, YW-z <br />ICC CERTIFICATION # 412, <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment 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 the local agency, inspected and certified <br />by a registered professional engineer having education and ex erience with underg-round storage lank system installations. <br />SIWATURE OF TA OWNER OR OWNER'S AGENT <br />DATE 494- <br />PHONE <br />/4 33,��' <br />.rint) 435. <br />CERTIFIER'S T�14-,/ 486] <br />(/- <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 4x8' <br />CERTIFIER'S CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />C1 I. TANK OWNER E:l 2. TANK OPERATOR <br />Jff'3. CONTRACTOR 0 4. PROPERTY OWNER <br />5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (1212007) -1/2 www.unidoes.org <br />