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Apr .07 14 10: 12a Elite IV Contactors 12094616342 p. 2 <br /> U1N°IF'IED.PRO:G CONS!DLIDATED p'.O R I . <br /> 'UNDERGROUND STORAGE TANK <br /> CE TIFI t!`I' QN OF' S 'LLAT ON'.�:MO . �FXCATXON <br /> R <br /> (One.form per project.). <br /> � r•r •E� � � ` r s+w a�,�a�3.;'�!i f.'�4xfca'�r�r°'�`a� ',: <br /> 11 W` <br /> FACILITY 1D.# ; <br /> (Agency Use Only) z { I MI <br /> .. s .. 4' <br /> BUSINESS NAME(Same as FACILITY NAhM w DBA-Dans Baiuss As) s• <br /> -BUS]NESS SITE ADDRESS tM WO <br /> - -.. ..:.. :_:: : _..103. .CITY.. ItLt. <br /> L- �1 NP 4 <br /> - -` a ,. 3 •' '--..: ..-.. xf s <br /> 1 <br /> ' .' .z '•i 1' :.uhf' .nom.SrS?.... .r...r s. r. <br /> TYPE.OF PROJECT.{Check d that p.RW :. ossa WORK A THORIZED UNDER PERMIT 4336• <br /> 0 11.TANK INSTALLATION QR.REPLACEMENT (Numhi:r Date): <br /> 0.2.PIPING INSTALLATION OR REPLACEMENT �y <br /> D 3.SUMP INSTALLATION OR REPLACEMENTSri l- CSQ c11 <br /> (�.d.CINDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER _ <br /> .DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> �C <br /> :$ SQ-T T�A <br /> A i 04Z Q <br /> NAME OF CONTRACTOR WHO PER INSTALLATION(MODIFICATION asm. <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# a ase` <br /> 0&13t; <br /> I certify that the information provided herein is true,accurate,and that thefollowing x ,ditions have been satisfied: <br /> • - The,.installer has met the.yequirements set forth in 23 CCR,§2715,subdivisions(g)and(f . <br /> The.underground.storage._tank,-any.primary-piping,:and.:any. secondary-containmew %vas installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • <br /> All work listed in the manufacture'r's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency,or if required b; to local agency,inspected and certified <br /> hy a registered professional engineer havin education and a erience with under rounJ :ora a tank astern installations. <br /> SIGMA F OWNER O ER'S AGENT DATE aas. PHONE 487, <br /> CERTIFIER'S NAME(print) 485 CERTIFMR'S TITLE: 486, <br /> NAME OF CERTIFIER'S EMPLOYER(AHA.) ase CNS 3 <br /> EkTIFIEWS REliATIO1 TO TANK OWNER 4M <br /> • <br /> (],I.TANK OWNER D 2.TANK OPERATOR <br /> l]3.CONTRACT <br /> S:OTHER A E A <br /> UPCF UST-C-.1P:... .. -----._...._._._._.._ . . _..._. . , ...... ........._,.._. ......_. ..... . .. Rev.(1212007) <br /> OR 0 7 2014 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />