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Jan 19 12 12:40p Elite Contactors 12094t""342 <br />W <br />-UNIFIED PROGRAM CONSOLIDATED FO <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION T11 <br />(One form.perproject). <br />FACILITY ID # (Agency Use Only) <br />9 2012 <br />,D]IFICATION <br />. . . . . . . . . . . . . . <br />PS <br />BUS S NAlvffi (Same as Facility Name or DBA — Doing Business AS) <br />.1 <br />A, <br />BUSINESS SIT.9 ADDRESS 103. <br />CITY <br />r <br />rL <br />t <br />4s3aWOR <br />TYPE OF PROJECT (Check all that ly) <br />❑ I. TANK INSTALLATION OR REPLACEMENT <br />(Nun <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />3. <br />0 33. SUMP L1dSTALLATIONY OR REPLACEMENT <br />E] 4. UNDER DISPENSER CONTAMAENT INSTALLATION OR REPLACEMENT <br />El 5. OTHER--- <br />* it Date): <br />DEs=noN OF WORK BEING CERTIFIED: <br />44V <br />483c. <br />... ..... . <br />NAME OF CONTRACTOR"O PERF INSrL71P!MQDIF1CAT19,N <br />P. <br />c_A <br />M_ <br />LLT 4 <br />CONITRACTOR LICENSE W( b- <br />eA -Z <br />I ICC-CERTMCA.TION i <br />c,nditions have been satisfied: <br />LIX <br />I ."ry <br />�7. <br />1he local agency, inspected and certified <br />I certify that the information provided herein is true, accurate, and that the followin, <br />8 The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) ar <br />* The underground storage tank, any primary piping, and any secondary containr <br />voluntary consensus standards and any manufacturer's written installation instruction <br />0 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 <br />by a registered professional engineer having education and experience with under o} <br />SIGNATURE OF TANK.OWNER OR OWI)ER'S AGENT <br />DATE <br />/,( V <br />I - <br />al Ig <br />E <br />.495 <br />CERTIFIER'S NA),6CERTHIER'S <br />h 410 1 <br />NAME OF CERTHUR'S EMPLOYER (DBA) a$gCER=R'S <br />RELAnGl <br />y* <br />1. TANK'OWNER <br />[3 3. CONTRACTOR <br />0 5.OTHER AUTHORI.1 <br />UPCF UST -C Rev. (1=007) -112 WWW.Unidomorgg <br />p.1 <br />JA N <br />9 2012 <br />,D]IFICATION <br />. . . . . . . . . . . . . . <br />PS <br />3. <br />log. <br />JTHORIZED UNDER PERMIT 483b. <br />* it Date): <br />483c. <br />... ..... . <br />482& <br />M_ <br />LLT 4 <br />c,nditions have been satisfied: <br />d:' was installed according to applicable <br />1he local agency, inspected and certified <br />-storage tank em installations. <br />a8a• PHONE 497. <br />486. <br />9 ?TOTANK*OANER 489. <br />E:1:2. TANK -OPERATOR <br />❑ 4. PROPERTY OWNER <br />I WENT OF TANK GviNER <br />