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JunL511 02: 09p Elite IV Contactors 12094616342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FOF-A <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /Mo ' )IFICATION <br /> (One form perprojcct.) <br /> r <br /> 7777777 <br /> :... <br /> T. FAC-IL ITY:'INFORIIAQN.:.. <br /> FACILITY ID#(Agencv Use Only) EL <br /> BU ESS NAME(same u F NAll, or DBA-Doing BUsneM AYa> <br /> /1` 104, <br /> BUSINESS S DDRESS dyn, <br /> t07.Q OhAI0 s /fit <br /> ':U <br /> IN <br /> • :., ION <br /> A.TIO�i''I,Mt}D�'ICATiON.PROJECT ITE <br /> TYPE OF PROJECT(Check all that sodv) <br /> 483& WORK A IAORIZED UNDER PERMIT <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT, (Numb:r Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT / <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT' C p� C f <br /> 5.OTHER — 483c <br /> tlj�CRFTION OF WORK BEING CERTIFIED_ <br /> 1�E—� CIA SSP �-_cc,u�� C% 5 t`E'k. �� <br /> �;�.������ta�t�� C:� til�e Tc��t�:�1 •.S� � <br /> CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 48a` <br /> CSG -77777-777-77777-77 . <br /> CONTRACTOR LICENSE# 48ab. ICC CERTIFICATION# ;„���LS✓ l�� 4482r. <br /> ti <br /> '.._Iy..CERTIFICATIOI*I:' <br /> I certify that the information provided herein is true,accurate,and that the following )editions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)an i). <br /> • The underground storage tank, any primary piping, and any secondary containnle t was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instruction::. <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 b. the local agency,inspected and certified <br /> by a registered professional engineer having education and ex erience with underarot:n _stor tri tanks stem installations. <br /> ATURE OF T K OWNER OR OWNER'S AGENT DATE4s4. PHrOME 487• <br /> JNAME <br /> ERTIFI AME(print 42, CERTIFIER'S TITLE: 486. <br /> CERTIFIER'S EMPLOYER(DBA) $ CERTIFIER'S RELATIOUS ::P TO TANK OWNER ass. <br /> ❑ 1,TANK OWNER ❑ 2.TANK OPERATOR <br /> 'Cj� <br /> � `\�\L ��� { �3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5,OTHER AUTHORIZE )AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(1212007) <br />