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Apr 04 02 07: 47a Elit Iv Contractors Inc 2094 1G342 p. l <br /> AEk <br /> li <br /> UNIFIED PROGRAM COMOLIDATIED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MO FIJ g J <br /> (One form per project) fail <br /> Wift <br /> I. FACILITY INFORMATION: APD A <br /> FACILITY ID#(.4genev Use Only) <br /> BUSINESS NAME(Same as r=11 tv Name or DBA—Doing Business As) E /A/COUNTY <br /> 3. <br /> A T' <br /> BUSINESS 5TTE ADDRESS jos. CITY 104, <br /> II: INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that annlvl 493'• WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> [3c5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: axx. <br /> qct " -4Wo _ ,a. `$c{ �r c t -kca�tkS � 4* 01l �i�ti:3 <br /> q a? a a l�a-s3 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION ax2a. <br /> LL t on <br /> CONTRACTOR LICENSE# 47'*2b' I ICC CERTIFICA ION# 4h'2c. <br /> 3_5 176 <br /> N. 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 irl'spected 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 underground storage tank system installations. <br /> SIGNAT OF TANK OWNS OR OWNER'S AGENT DATE 4W. PHONE 437, <br /> 3-a5- 0S ( cam } �I- 33.7 <br /> FIER'S NAMj(psi �^ 435' CERTIFIER'S TITLE.• 4U7 <br /> ie- Sedor v C c K <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 433' CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> r t ❑ 1.TANK OWNER El2.TANK OPERATOR <br /> t,Z4 e S V ❑ 3.CONTRACTOR ❑ 4,PROPERTY OWNER <br /> T OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />