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Jul 11 02 08:32a <br />Elite Iv Contractors Inc 2094616342 <br />0 0 <br />4b � -, Y-1/ 33 <br />UNIFIED PROGRAM CONSOLIDATED FORM 01F <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION MODIFIC* <br />(One form per project) <br />�J_ i ITY1, <br />kL <br />ACI <br />FACILITY ID # (Agency Use Only) <br />BUSINES6 NkME (Same as t'cilip Name or DBA –Doing Business As) 3. <br />— <br />BUSINESS SITE AD - <br />DR103 ?;SV /I <br />104. <br />Crzy <br />INSTALLATION! MODIFICATION CTDES.CR1PT10N-,:.-., <br />483,. <br />TYPE OF PROJECT (Check all that gypt <br />493b. <br />WORK AUTHORIZED UNDER PERMIT <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />0 3. SUMP INSTALLATION OR REPLACEMENT <br />0 4. UNDER DISPENSER CONTA[NM[ENT INSTALLATION OR REPLACEMENT <br />[1 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br />171 <br />CONTRACTOPINFOTION*..!':: <br />?NAME OFCONR OPEAME;KNSTALLATION / MOD CATION 492a, <br />482b <br />CONTRA OR LJCENSE # . <br />8, <br />492c. <br />ICC CERTIFICATION # <br />z3 RP <br />F <br />V <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manufacturer's written installation instructions. <br />• 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 the local agency, inspected and certified <br />by, a registered professional engineer having education and ex erience with underground storage tanksystem installations. <br />SIGNTURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />7` <br />1 00)IUI-03�4 <br />- <br />TIF ME (print) 485. <br />CER R'S TITLE: 466. <br />NAME OF CERTJYIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 439. <br />[D 1. TANK OWNER 0 2. TANK OPERATOR <br />r*y3. CONTRACTOR C] 4. PROPERTY OWNER <br />- <br />S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />�'. V - - - I . __ . I <br />VPCF UST -C Rev. (1=007) -1/2 <br />ww,.v.nnidocs.ora. <br />