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IJul•27 12 11:56a <br />Elite IV Contactors 12094616342 p.2 <br />UNIFUD PROGRAM :CONSOLIDATED T )RM <br />UNDERGROUND STORAGE TAN; <br />CERTIFICATION OF INSTALLATION / A DDIFICATION <br />ON"k ?" AMR ...a�. K^xa°�'Swsa--- ap • a�3 �` r'R"—- <br />'�1- — _ <br />;enc} Use Only) i p <br />(Same,=-F=dity Varve or ABA— Doing BusinessAsJ 7. <br />>DREss <br />j <br />551 -io <br />TYPE OFPROJECT (Check all NK thatannly) ate' WC(Av m 'U YLUTHORIZEDUNDER PERMIT `3b. <br />=1 I. TALN5TAU ATIoNOR REPLACEMEN f: ' a • or Date):. <br />'2..PIP]NG INSTALLA.TTON ORREPLACEMENT <br />tdlt' <br />3. SUINSTALLATION OR REPLACEABNT <br />(]; 4. UNDER DISPENSER CONTAiNMEN INSTALT.ATION OR REPLACENIENT t" ••+ <br />5. OTHER - <br />ESCR TIOXOF.WORKBEINGCERTIFIED:................... <br />H c C ec C' C _5tiu {.�J �(1 5 -t i �t cX" J �}ir ! A <br />`� 1 �ti <br />?k1�j -� 75iCp tf .:bOc. Oru� v <br />A11 W l 5 -i is �' � t� ctC �k� �c, cs dje�e4 <br />:ems .+. <br />NAME OF CONTRAC£OR WHO PER FORMED INSTALLATION I MODIFICATION e 45ML <br />CONTRACTOR LICENSE # 4"482r - <br />ICC 'CERTIFICATION i rr�� <br />s <br />1 ..%. <br />certify that the kronnation,provided herein is: true, accurate,_ and that the following c nditiions have been saf diied:. . <br />• The instailer3sas met there <br />quirernents set forth in 23 CCR -§2715, subdivisions (g) ani i <br />® The vndergrotzud storage •rank,any pry .Piping, and any secondary contaiim;ei was installed according .to appiicble <br />.voluntary catisensns-standards-and any n=ufacturer's written izistallkdon instructions. <br />. All work listed in the manufaotilrer's installation ch=Wist has been completed. <br />The inatallation.has been inspec d'and approved by the localagency, or if required Iry lie Iocal agency, inspected and certified : <br />b a-' ed rofessional engi2eer baying education anda cs iffi.under oualc :;fora tank stem installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT, DATE Y. }� PHONE ate. <br />(` ' ) <br />CERTIFIER'S N 7 4 CE7tiIFIERIS.TTi - - � 46G. <br />NAME OF TTFIER'S aeLOYrER (DBA)48& CERTIFfEWS•RELATION"FI ' TO.TANK OWNER ° <br />��� e ®',1, TANT QVI+NER" �.'2, TANK -OPERATOR . <br />3. CONTRACTOR .. D 4. PROPERTY 01AWEIt <br />OTHER AUTT30RMf 7) t GENT OP TANK OWNER <br />UICFVST-C Rev.:(12=97) -112 WWW.anidoc4rg . ::' <br />