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Rprt07 14 10: 12a Elite IV Contactors 12094616342 p, 3 <br /> Mar 04 14 08:06a Ela a IV Contactors 1209461 42 p. 2 <br /> ?AbE <br /> eu , <br /> CiNTFIED f'ROGRAitiI CUNSOLIDATEi1 FORK <br /> UNDERGROUND STORAGE TkNK <br /> CERTIFICATION OF INSTALLATION I M('. ) iFiCATION <br /> (One farm per project) <br /> FACI[.rrY tD k(AgMY Use Only) ; <br /> 3. <br /> BUSINESS NAME(Same as Facility•Name or DBA-Doing Business AsJ <br /> i c Itlr. 1 CITY :ae. <br /> BUSINESS SITE ADDRESS <br /> J[I. TNSTALLAT7(ON 114ODIFICATION P1�Q3fECT L_ SCRIP 1'I4N , <br /> TYPE OF PROJECT(Check t s ryJ Als- WORK,% N?RILED UNDER P5112MIT arm. <br /> I WOO <br /> [1 1,TANK INSTALLATION OR R.&LACE-HENT (Namiw� se): <br /> ❑2.P[pING rNSTALLA71ON OR REPLAC DdENT ,�/� <br /> [l 3.SUMP INSTALLATION OR R PLACFNSNT � W{S1C'� <br /> �.t1LYDER D(St' BSER GONTAIhlvfEl�T rNSTALLATiON ORREPLACENTNT <br /> 5.OT}3ER ori.. <br /> I)ESCP[PTIO'4 OF WORK BEING CERTIFIED: <br /> iEC:.Nc Ctl C,;[ ''�'' �3.T1S�'�C���.. CY�YI.�t'611� �3r'�{,`�'.. :�' �,� •'� +Ge.�' "`.,1 <br /> ��.1 Cc"�i�'t�5 t t5� P i c3��.crt�t� af� �n� � �'•SQi�l �:t:. T't Klt�t�.�•µ�" <br /> r <br /> ��; �.-t3�SfE:�,E�ti 7�kiS Qty tti�p(:r�-)•�i�a . <br /> m� orcToR ib4bx :Tio,� <br /> .. .. ..• 112a <br /> NAME OF CONTRACTOR WHO PERFORMED IN'S'r'A'LLATION/MODIFJCAT ON <br /> « .... <br /> 4m, <br /> CONTRACTOR LICENSE 4 �^/�f�Sl/r, t�Cy�RTIFSCA3 rON# <br /> IV. GERTI[ IGATYON <br /> I certify that the information provided herein is true,accurate,and that the following : d'ations have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)an(;t <br /> • The underground storage tank, any primary piping. and any secondary containm:r was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructiom. <br /> All work listed it,the manufacturer's installation checklist has been completed- y <br /> The installation has been inspected and approved by the local agency,or if required :+ rc local agency,inspected and certified <br /> 1. <br /> NE <br /> by a r • erect rofessional est ' ter'flavin education and ex encs with unde ou;. trrae a taOs em installations. act <br /> StGN OFT INNER OR OW�tER'3 AGENT DATE x J7 �,a <br /> l,J'�3-Ga��_ (21 21 <br /> �1 t <br /> acs. CERTTIER'STITLE: <br /> 11 <br /> t~ FiEwS NAME.(print) <br /> aasLzia <br /> N_ANv1EOFCERTIIrIER'S EHIPLOYER(DBA) <sa. CERTTFLF.R'S TANK OWNER <br /> RFLATiOT�:�: 'TO <br /> a0 <br /> ���V L] I.TANK 0%'NER 0 2.TANK OPERATOR <br /> _LCL L �3.CONTRACTOR ® 4.PROPERTY OWNER <br /> ❑ 5.01NER AUTHORG:° AGENT OFTANK OWNrIl <br /> UPCF LIST-C Rev.(I2120*7)-112 w".naidocs.org <br /> RECEIVED <br /> APR 0 7 .2014 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />