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Jun 30 11 11:23a Elit-90KV Contactors 12094 342 p.2 <br />V a <br />M1 as <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MOE IFICATION <br />(One form per project) <br />o "PENN!.. <br />I. FACILITY INFORMATION <br />FACILITY ID 9 (Agency Use Only) <br />MESSNAME (Same as FACUTY NAME orDBA — Doing Business .4s) <br />� wv-�—\ 3)t� <br />CITY 104. <br />t <br />_11. <br />. <br />INSTALLAT10N:1 MODIFICATION PROJD <br />ECTESCI IPTION <br />TYPEI . OF PROJECT I (Check all that . applyas;aWORK All? 10R.IZED UNDER PERMIT 483t, <br />F1 1. TANK INSTALLATION OR REPLACEMENT. (Number ur oe): <br />2. PIPING INSTALLATION OR REPLACEMENT <br />3. SUMP INSTALLATION OR REPLACEMENT <br />F1 , 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />V u -T s,� EA� <br />\16,n wqj <br />6.0 "50c) t� v ) <br />tf,-IWWY� i�)P 6 itJd K�:)l � rho jex. 'sd3j <br />14 <br />2-zf <br />`112ct-2L'11 at haml <br />111—CONITRACTOR.INFORMATION <br />nP MMTIZArTOR VJT4C1PFRF0RNIRD INSTALLATION/ MODIFICATION ab'' <br />CONTRACTOR LICENSE 9 <br />[CC CERTIFICATION 4 <br />.. . ....... <br />IV. C RTIFICATIQN;"..­... <br />I certify that the information provided herein is true, accurate, and that the following cur litions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (:I) <br />• The underground storage tank, any primary piping, and any secondary containment t Yas installed according to applicable <br />voluntary consensus standards and any manufacturers written installation instructions. <br />• 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 by tl - local agency, inspected and certified <br />.by a registered professional engineer having education and experience with underground s ).-age tank system installations. <br />OF TANK \VNER OR OWNER'S AGENT DATE <". I MuNt -7 <br />NX,N <br />CERTIFIER'S A(pin) 495 CERTIFIER'S TITLE: <br />NAME OCEIFIERIS tM_P;AER (DBA) 489 ERTIFTER'SRELATIONSI-IF [OTANK OWNER 489, <br />g O <br />� 'L� - �W� — — [] L TANK OWNER 2. TANK OPERATOR <br />k &nc� 1a;. CONTRACTOR 4. PROPERTY OWNER <br />El S. OTHER AUTHORIZED, _:ENT OF TANK OWNER <br />LTPCF UST -C - 1/2 Rev. (12/2007) <br />