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a,. 3u�'i 13 12 08: 08a EliteIV Contactors 120946342 p. 2 <br /> UNIKED PROGRAM CONSOLIDATED IX :;M <br /> UNDERGROUND STORAGE TAM, <br /> CERTIFICATION OF INSTALLATION l 10 .)DIFICATTON <br /> � `:stn _ Z x•a <br /> - w _ .. ,,......, '�akm.ai.�a. ,.,.,:aar, .rt.•: -".� i x� <br /> v <br /> FACILITY ID 9(Agency Use Onh) <br /> P <br /> 13USINESSNA1vM(Same as Facilily Name or DBA—Doing BusFecss <br /> .BUSDWSS'SITE ADD fps. CrIT 104. <br /> .ca. "+•:"s' ., t y a. <br /> 'TYPE OF PROJECT(Check W that g2 ��" WON K UTHORIZ.ED UNDER PERMIT 493b. <br /> -Q 1.TANK INSTALLATION OR REPLACEMENT: .(Nurfb arDate): <br /> El 2..PIPING INSTALLATION OR'REPLACEM T <br /> 0:3.SUMP INSTALLATION OR REPLA:CEMEA'T <br /> 0:4.UNDER DISPENSER CONTADMIENT INSTALLATION OR REPLACEMENT <br /> ] 3:OTIIER — <br /> __ <br /> _ . _. <br /> t .. <br /> x <br /> g �., . <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION - <br /> C�(l� r <br /> COMMACTORLIC'ENSE# ° ICC'CERTIFICATION# <br /> pco <br /> L 1 LSI <br /> I certify that the information provided herein is true,accurate,and that the following c nditions.have been satisfied: <br /> The installer.has met the requirements set forth.in 23 CCR§2715;subdivisions(g)and t ;. <br /> ® The undergrollhd storage tank any primary piping, and.any secondary contammez was iustaUed according to applicable <br /> _ vohmtary coniensus=standards-and-any:manuft caver's'written in W,lsfioninstructions. <br /> All work listed in the manufacturers•installation rhaddist has been completed <br /> • The installation.has been,inspected and approved by the local agency,or'if required I ly lie]0621 agency, inspected and certified <br /> b a fissional en ' eer havin education and erience with under uuc .orago tail]; em installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DAT'S.. 4k. .PHONE 4s f <br /> IbR <br /> 'S N irt) 485 CERTIFIER'S TITZ E:. _ _ 4e6. <br /> NAME OF COTTIFESIUS EMPLO-xqM(DBA)`�"p 4U. CER 'S RELAnCN.'H 'TO TANK'OWNER 4 <br /> 99. <br /> j�3.' <br /> 2.T•A�OPERATOR <br /> CONTRACTOR [] 4.PROPERTY OWNER <br /> _OTHERAITTHORIZI- kGENT OFTAM OWIWR" <br /> LV CF UST-C Rev..(%2f7a7)=It'' :nn ve aseldn orQ". . <br />