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i <br />Fiug'02 11 08:49a Elite IV Contactors 12094616342 P.5 <br />0 6 <br />X15 <br />15 <br />C <br />UNIFIED PROGRAM CONSOLIDATED F('. 1F 0 <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION Ni ]DIFICATION <br />(One form per project) <br />L FACILITY INFORMATION: <br />FACILITY ID # (Agency Use OnJv) FIT 1 11 <br />BUSINESS NAME (Same as Facilitv Name or DBA - Doing Business As) 3. <br />A <br />BUSINESS SITE ADDRESS 103 <br />CITY 104. <br />L <br />JM INSTALLATION /MOD.IFICA.TIONPROJECT -',ESCRIPTION.: <br />TYPE OF PROJECT (Check- all that aonlvJ 413, WORE, p )rHORLZED UNDER PERMIT 4836 <br />El 1. TANK INSTALLATION OR REPLACEMENT (N=Lct -j- Date): <br />El 2. PIPING INSTALLATION OR REPLACEMENT <br />0 3. SUMP INSTALLATION OR REPLACEMENT SLI cnt <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />El 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: <br />L <br />M.` CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION' MODIFICATION 4824. <br />CONTRACTOR LICENSE # 4"" ICC CERTIFICATION # 482c. <br />C <br />CERTIFICATION, <br />I certify that the information provided herein is true, accurate, and that the following c, 3.ditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and ( ). <br />• The underground storage tank, any primary piping, and any secondary containmun -was installed according to applicable <br />voluntary consensus Standards and any manufacturer's 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 he local agency, inspected and certified <br />by a registered professional engineer having education and ex erience with under our_: d iorage tank system installations. <br />Q <br />SIG OFT�A;NKO ER OR OWNER'S AGENT <br />- <br />I DATE 484- PHONE 487, <br />CERTIFIER'S TITLE! 486. <br />RTIFIER'S NAME nt) <br />L 1 , <br />aN-e-) <br />-11-` \x� <br />CERTIFIER'S RELATIONER TO TANK OWNER 499. <br />NAME OF CERT IKjpk1S EMPLOYER (DBA) 488. <br />1. TANK OWNER [1 2. TANK OPERATOR <br />3. CONTRACTOR L-1 4. PROPERTY OWNER <br />❑ 'SOTHERAUTHOPJZEr- %GENT.OF TANK OWNER <br />UPCF UST -C Rev. (12/2007) -1/2 <br />www.unidocs.org <br />