Laserfiche WebLink
Feb 02 12 10:00a Elite IV Contactors 120946 342 p.I <br />UNiF1ED PROGRAM CONSOLIDATED F lRM <br />UNDERGROUND STORAGE TAN -K <br />CERT CATION OF ITSTALLAMN ill r DDIFICATIQN' <br />..(One form per project).. _ .. _ <br />FACILITY ID # (Agency only) m �,. <br />BUS IS NIAME_ (Same a�Fgcility Name ar DBS( Doing Bussinners ) <br />t, ` ice• ,f � c•i-��..I::.:fi <br />BUS s SITE ADDRESS r ,�. I03. — <br />� 104. <br />d7z 11-;ZEn;7 <br />. K <br />Ng <br />TYPE OF PROJECT (Check all that annly} : 483a . W0 • : j" a <br />1 <br />� I. TANK INSTAI:.LATION OR REPLACEME2VT ' .K UTFIORIZEDUNDER PERMIT 483b.(Nm nE - or Dale);. ' <br />.0 2.. PIPING INSTALLATION OR RERLA.CEM M, -f <br />Q. 3. SUMP INSTALLATION OR REPLACEMENT <br />4. UNDER DISPENSER CONTANMENTINSTAI.LAT70N OR REPLACEMENT <br />5. OTHER <br />3SCRIPTION OF WORK BEING CERTIFIED: . <br />-..;�t:.i <br />U6 `✓rC�,, <br />P. <br />t/'•Li-,,r. <br />NAME -OF CONTRA A WH(Oip/ % OR—ng� /INgTION I MODIFICATION. <br />L 1W t �'' f y 487a. <br />yr .. <br />CONTRACTOR LIC 34SE ICC. <br />TNTC T N' 1 f 4M <br />fes; �-% 2 <br />l <br />_ <br />T certify that the tnfoxmaiioat provided harass is true, accurate, and that the following ro didons have been satisfied: <br />® The installer has uief the requirements set Earth in 23 CCR §2715; subdivisions (g) and (h <br />• The .uadergrouiad storage tank, any.grimary ,piping, and ally secondarycontaintriefft vas installed according to applicable <br />yoluntaryconsen=s tandm*-:and any:manufacture;'.s written icsSWIatiori-instiuctions: <br />All work listed in the maaufacturer's installation checiciist has beenconipltted <br />+. The installaiion..has been inspected and approved by the local agency, or -if required by.t; ; Iocal agency, inspected and certified <br />b .are 'stared. fessional en ' ear havin education and ence with under ound :s �: a tank' Stem inst3llationS. <br />SIGNATURE TAMC O ORO AGENT 494: -PHONE <br />.CER •S'H <br />(priest) 4 <br />S.T' aes <br />CER <br />. TIFMR' - <br />:. . <br />NAME OF CERTIFIIER'S LOYER (DSA} ?,5 <br />r TTONSFT TANK OWNER <br />� .F (). 484.. . <br />.. j j'I.TANICOWNiIt :i 1'2TANK'OPERAT'OR <br />© 3. CONTRACTOR ' . 1 l 4. PROPERTY OWNER <br />RIZED Ati D E•:Iv 5: OTHER: AUTEiO "I' OF TANK OWNER": <br />UPCF LIST-C.'Rev (IV2007) -1/2 www noidoaso <br />' - i <br />