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Flug124 12 11:03a Elite IV Contactors 12094616342 p.2 <br />0 0 <br />UNIFIED PROGRAM CONSOLIDATED Fojkr <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION 1 M10 I)IFICATION <br />(one form per project-) <br />FACILITY ID 9 (Agent} Use Only) T-1 <br />BUSIX NAME (sam.acy.ANJ� �n,�DBA- Doing B=n= As) 3. <br />TYPE OF PROJECT (Check 1!that atmly <br />F-1 I. TANK INSTALLATION OR REPLACEMENT <br />0 2.PIPING INSTALLATION ORREPLACEMENT <br />0 3. SUMP INSTALLATION OR REPLACEMENT <br />[:1 4 -1;N -DER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />�►� : W4k <br />-.A,2 <br />9 <br />LICENSE # <br />I ! <br />,"T,DESi ]UPT-10K, <br />WORKAI CAORIZED UNDER PERMIT 493b. <br />(Numb.zri Date)-. <br />lild 6OW/b OV, <br />and <br />FORMATION <br />ICC CERTIFICATION 9 <br />IV. - CERTIFICATION. <br />I certify that the information provided herein is true, accurate, and that the following L( iditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions and I <br />• The underground storage tank, any primary piping, and any secondary containm.:n was installed accordin., to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />4D 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 '-e local agency, inspected and certified <br />by aregistered professional engineer havi2p, education and exl?p—rience with �Lnder�grour d :cora tank system installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 1 1 P 411, <br />1,*17 <br />Z612 <br />(print) . , A ' <br />ERTIMER'S EMP YR (DBA) CERTIFIER'S RELATIONETI 'TO -MNK OWNER <br />., <br />El L TANK OWNER M 2. TANK OPERATOR <br />CONTRACTOR El 4, PROPERTY OWNER <br />L,c � Ji <br />LOC. <br />[ 7&S'OTITERAUTHORIZEE AGENT OF TANK OWNER <br />UPCF UST -C -112 Rev. (1212007) <br />