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.Nov $ 1 11 08: 05a Elite IV Contactors 12094616342 p. 2 <br /> UNEF ED PR6gRAM CONSOI IDA1 E <br /> UNp?ERGROUND STORAGE T.0 IC <br /> k1VS <br /> CFCATICDlgr()F TALI.A' 'I()��F .t11[C?DLTCA7CSUN <br /> . .. ' :•.. ..((}ne forrn•perpraject)...__. <br /> NMI-0 <br /> ,. <br /> FACILLTYID•# r1 ;. ..., •�„ x. '� _� ,^ �,, i`�' + '-' � <br /> t 8errcY Use Only) <br /> "BUStNFSS NAME <br /> (Same as Facility Name orDB�f-DaingBrermes5.6sJ <br /> `. <br /> s. <br /> BUSATESS SfTE'ADDRESS <br /> M CITY0 <br /> -4 <br /> v x <br /> ... 9 a •:, - . .n0:. ...rte ,rs�_ <br /> TI'PE OF PROJECT.(Che k a that IvEffr <br /> _ sx <br /> D I.T1NvK. ASTA <br /> ILA70ROR IEPIAC +�rT <br /> 3.AUMOR: <br /> M UNDER <br /> PRvTfl2P <br /> awnIPINGXSTAUA77ONORREPLACgOim t eror Date3.8CIPinSTALLATTOd <br /> OR REPLAtEN(�1T <br /> L7 4.UNDER DISPEN=SER CONTAROnaT <br /> '0S.OTHER A' AI L.ATION Qlt•REPLACEMEtvT <br /> DESCRIM0iV OF WORK"$EtNG <br /> 453� <br /> J C:fY)e j hCG;C° <br /> CC. <br /> - <br /> NAME OF CONTRACTOR.W730PERFORhINSTALLATTONIMODIITCATION ter : <br /> CpRTTRACTOR T.ICENSE# aaz� TCC' CATION# <br /> 1/ / -} ask. <br /> (� f l <br /> . - t <br /> w . <br /> gg <br /> I certify that the txtformatioTaPropided Iaerein is tzue,accurate,and that the foIIoae ca' Iirtlous kava beau satasfied: <br /> • The-installer.hasmet the re <br /> guirmumtts set forth in 23 CCR§2715,subdiyisaons.(gj and(.i) . <br /> • The tuadergroxuad..stoI tank, any Primary piping..and any secon <br /> voluntary_conseasos.standards and any °On �l`" as installed according to applicable. <br /> y.maai?ufactnrer's written mswlafion insctuctiozrss <br /> • <br /> All-work listed in-the 7W hat'er's•i6stalli6on*cheekiist has b=een completed <br /> The installation has.been inspected and approved by-the Iocat a ea <br /> b are 'stared `Iessional en e�r haven' education and cy'or if regtared by-,,h local agency,inspe�and certi5ed <br /> SIGNATURE F T. OWNER R WNER'S AGENT enience'witlr and tend tc aLQe taIll[ stein lataaus. <br /> 1 <br /> ;DATE e4_ 'PHONE esz <br /> N <br /> 'S NAME <br /> rin_) �✓, ass.- _ (?_ Vit) C l 'J`✓� <br /> - �. CEitT7FFER'SZTII.E:, 496. <br /> IdAMEOF CERTIFIER S PtvIPLOYER(DBA)' axe C•�' - <br /> CEtZTTFiE[t S RELATIOinTS 21 ANK owNER axg. <br /> 1_T I:zrxoWNSR <br /> J 2:TANK PERATOR <br /> L� <br /> 3.CONTRACTOR . f.PROPERTY OWNER. <br /> (� <br /> S.OTEER AiFIT30RtZ£D A�iE iT'OF TANK;OWNER <br /> UPCF:UST-C Rev.(I2&07) <br /> ' tvrvw emidocs.org <br />