Laserfiche WebLink
Sep 13 12 09: 17a Elit IV Contactors 120946 342 p. 2 <br /> -UNIFIED PROGRAM CONSOLIDATED ,RM <br /> UNDERGROUND STORAGE Trti1. <br /> CERTIFICATION OF INSTALLATION/C� 0 CATION <br /> _ (Qne fgrlrlpezpspject)..._ <br /> -.._. .._ <br /> w' <br /> FACILITY ID#(Ag-ey Use Only) ry <br /> :BUSINESSNAME(SanwosAaalityNwne.orDBA-Doing BusineesAs) . . 3. <br /> BUS DVESSSITEADDRESS � - .CITY too. <br /> NL <br /> TYPE OF PROJECT a. W483b.cNM . <br /> Q.I.TANK-WSTALLATxoN_oR REPT ACEMEtvT <br /> 2-PIPING INS1'ALLATION.ORP"LACEMEN7 �^ <br /> 3.SEYWINSTAI:I.ATiON.ORREPIACEMENr <br /> 0,4.UNDER DISPENSER:CONTAINMENT INSTALLATION OR REPLACEMENT; <br /> -DESCRIIG''ION-OFWORKBEING•CMZrMW:...-._____ <br /> Ell F1C1'41lULl�'i <br /> F <br /> ha <br /> 51 <br /> lEm <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION_ ' <br /> ,1 <br /> CONTRACTORLICENSE# \ ICCCERTTFICATiON: 3 a ` 4M <br /> .1 certiy_#hat the ihfoipu4i a prapided herein is true,ace eirate,and that the foIlowin;t; ►adations have been satisfied: <br /> The i distatYex Itas mete z egts'sct forth in 23 CCR§2715 'sudivisions(g)an3 I).' <br /> ..._ The zm <br /> derground storage"tank, any primary.pTmg;:and;any secaniiary contamn�e t was Installed'according to applicable- <br /> Ile <br /> on=xnstruction: <br /> .=. - ®",..A:Yl.-evozIr3isteet�iuthe maaaifactclrer's:instaYYation�sheakIist has-bean-campleted: <br /> •'. ."nie installation:has been <br /> inspected'aud. ved b file Iocal-. ' g cy,inspected and ceitified" <br /> , appro. p agency.,or, "required.a� the local.a en <br /> b "a' staredpEfessional . eer:havin educ:adon and rience with• um :to tank ern installations. <br /> SIGNATURE OF TANK OWNER'OR OWNER'S AGENT:. DATE - '. .. 180 PHONE <br /> 481. <br /> oas. • <br /> NAI4E OF TIFiEIt'S EMPLOXEft(DBA)' ! CERTTmwS RELA.TIOW iF F TO.TANK OWNER 489. <br /> TAMC OWNER' (],'2.TA' K-OPERATOR <br /> - �E1.3•.ANTRA LTOR ..: I� 4.PROPERTY OWNER <br /> l] S.OIN ER.UTM RIZ EE d.GENT OF TANK OWNER <br /> z- ,IIPCF usVc]2ev.(I2 m7)-IFL. wwwAn <br /> a . •I! t . , 4 1. <br />