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Feb 20 13 10:12a Elite IV Contactors 12094616342 p.2 <br />r: r s s r . w v t , -,s��, .. .:�G:^;ro';"-: a ° " 4 , ' r a t t ! " :t' ..., � _. . � •• p .e"F. '} x ' _b ► r } • a � s a <br />! r 1 7 <br />! <br />! ! ^ r UNDERGROUND STORAGE TAM', r <br />CERTMCATION OF INSTALLATION1.IN OI?IFICATZON <br />r <br />(One form per p-jCC0 <br />�AclLrrxID 4•(age use 0h) <br />USINESS jNAt�iETT11-1 <br />3 <br />Got 1 <br />BUSINESS SITE ADDRESS tai• all Baa <br />Ii <br />TYPE OF PROTECT' (Cbeek an Pint aea(v) aa'' WOR I :U� IiOR IZ13) UNDER PERMIT asst <br />Q 1. TANK INSTALLATION OR RMI A.MI ENS•; (Ntm jb x Rater <br />[] Z PIPING INSTALLATION OR diFsPT.ACEIaIFN'i <br />CI 3. SUMP INS'T'ALLATION OR: REPLAC&7vIENT C C' <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION ORREPI.AC M NT � �' � �.Jt...) {_•51 <br />5.OTEI1 R <br />DESCRIP iTON OF WORK EETNG CE#tTIFIEO: <br />1 pit 6ae a: R d <br />-TL <br />I ID Sec m <br />NAME OFCONTRACTOR WFTOPERFOR)vIED IlISTf1Li14TIONIMODIlTCATION <br />}'^ asaa <br />- .�.•W, 4J �l.3��I'�t-7 r .0 .. <br />CONTRACTOR LICENSE # <br />• t,SX.t?�s" (� ... �'�.J`t�:_. � ICC CER�ICAITON0• � seat. <br />tJ t t <br />UZ-- - <br />_.� _ _• _ _x 9 � i�a%rzusa�iozaTrovided hemin-'is-tme; recurate, aid -that -tire foiiaw�ing �:o' ;igtians t�a^ve beers ssJeiisfied: <br />_ ' • The installcr kas mot 1 Te_ regnirement set for in -23 -CCR- X27 -15; -subdivisions (g) and ( ij <br />Tlze.undergcound stnxage tank, • rxsn x -m and".an sec coiaamxent ras installed according to, applicable <br />vo nrTtaxy.co;tsensus start 0n . . <br />3 an any Than CtnFCr S W11f1813 <br />on: Instructions. . r <br />+ 'All ivor3c lisied'iT� the naanlifaciurer's insiallatiori chee si'bas bcen co meted. <br />® xh instailatiou::has..heen inspected and approved by'the local "Or, ifregnired by tE local igen ' <br />cy, Ins C6C and certified <br />h re 'stered mfessionai en 'Berhad edazcation and a erTence with under and st ca a tanks stem anS. <br />src oatc.sz _ <br />Q7 <br />i'ER° �� - .. ass • <br />, CERTTFi�R,'s ass ` ; <br />. ass <br />NAMTs.OB CERTIFIER'S EMPLOYER <br />Btl - <br />} ( RtTP7EIt'u'12 LATTON$i l �: YtAdV3CO0. diiNF�t asv. <br />L1 1 t Y \V J`� 1. 1� .� } v .0. 3. COk�1'T7rA [ 4 PROPffiO3i Q�It. j <br />I <br />. <br />Q 5.OTEIER:AU?1ZED.LC iiT ?F-TA2IIC0WN12 -. ...: ;.. <br />t <br />U;PCF UST -C - I/2 Rcv. (I2f2 MV <br />