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I M <br />Jun 24 11 07:05a <br />Eli IV Contactors <br />12094 342 <br />p.2REOgNtD <br />UNIFIED PROGRAM CONSOLIDATED F 1ItM — ,— <br />UNDERGROUND STORAGE TAl✓'lC <br />CERTIFICATION OF INSTALLATION / N 13DIFICAMNMENTALHEA <br />IT/SLICE <br />(One, form ,per project). <br />(Agency <br />tsualNrlsb "'AME (Same as F--fifYName or DBA —Doing Business As) <br />Ll T L <br />06_m TT thes�,t q,561U <br />VRN4 <br />[f gfixU7'�[a0'7(1'I+1}r"t3.t'%DNS <br />TYPE OF PROJECT (Check all that annly 491L W OI X k UTHORI2T U UNDER PERMIT <br />0 1. TANK INSTALLATION OR REPLACEMENT (ATuc aEor�D1ate): <br />2. PIPING INSTALLATION OR REPLACEMENT I SOV <br />3. SUMP INSTALLATTON OR REPLACEMENT ' e 3.xCJ <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />S_ OTHER <br />)ESCRIPTION OF WORK BEING CRRTYFrFn• � <br />5 - (ap�em}- ou f) 2 W 06-Y f) <br />- <br />all <br />AME OF CONTRACTO/R((,W\\HO P--ERF(/ORMED INSTALLATION / MODIFICATION <br />CONTRACTOR LICENSE # 482b. ICC'CERTIFICATION # <br />a .�. x R.:r.a .w......_ _-52 Vit(- i�: .52�$s�k� - pct At . <br />I certify that the information provided herein is true, accurate, and that the fbUowing .:c i ditians 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 containnical ivas installed according to applicable <br />vOluntary consensus standards and any manufacturer's written installation instructions. <br />• All wort: Iisted 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 A. Iocal agency, inspected and certified <br />by a ie ered professional en 'neer havingeducation and experience with under ound : cc aee tank system instaIiations- <br />SIGNA -65TA OWNER OR OWNER'S AGENT DATE 484. PH()NR 4x� <br />I CERTIFTER'S NAME <br />NAME OF CERTIFTER'S EMPLOYER (DBA) <br />y UPCF UST -C Rev. (I2l-007) -112 <br />II <br />5L� tet , , t 1_ I (2 1 ) 9&t 635-7 <br />RTJFiEWS TITLE: 481 <br />CERTIFTER'SRELATIONsi-'IT r0TANKOWNER <br />1. TANK OWNER 2. TAJO:-OPERATOR <br />,i. CONTRACTOR 4. PROPERTY OWNER <br />S. OTHER AUTHOR=. a iENT OF TAMC 0%WP_R <br />www.anidomorg <br />4S3b. <br />