|
R$.r 14 11 08: 59a Elite TV Contactors 12094616342 p. 1
<br /> UNIFIED PROGRAM CONSOLIDA'T'ED:f+( .'M k -f
<br /> UI�`DERGROUND STORAGE TANY 2011
<br /> CERTIFICATION OF INSTALLATION/.10 ')DI 'ICAT110
<br /> (One formper.project)- _
<br /> ... ,.„ ibx't t,w»M wn +g. -H'.ai * eft eai-ti; +5:.,. ¢i.• ,.fines'" .:a ren r � 't _
<br /> �a ,5,y4� ''q'°"„���"'�°i-....y i., �-�]' ,y-1 'y � �d' ^.r > A is � s�'• °�� `^�. :.
<br /> 3,'��'•'44x�- L x-!nR xt`Y 4- .'-°�''."rr '�”;!n did '4 �}R'{�k.. ��i;,�:SE,�'�g������� 6 t.r°� i.y"Y• w s y � #�e�e i �5.�,
<br /> ...:..�G,....s_�r':`,� "f-s:..x'_.'a�! E�'+_:h.':tk?'�'bwL_.,,':?'...a �..w;,$..f,�• .:�,::,.x z.. y-.-rr «...->. c.»s.,+a�R .3+�..e..�-... �-.•y 7 :+.,.u;2�+x .F.:+.`.�.•tr ,s,r..•.x�.. .,a_ .;3
<br /> FACILITY ID!1(Agency Use Only) IRE
<br /> J:
<br /> BU S N (Same as Radh ear DB,4-„&ging Busin s As) � 3.
<br /> Wont/
<br /> f t -
<br /> BUS S'SITE AD S C iea.
<br /> a~ 3`_ +» [•�tpy�zq, sn 9.:t:s -ms'ss -� -. -(� may”�' y. s w!'
<br /> :V;:Y`°' �G�' •^.,s r.�-�Tm d 4 xe_.>il�7f �� �� .:�u#� ��•••• �� ,7;7 i,�,x�?.:^ ax`? ie:; �.t� ..r•a:+�;
<br /> TYPE OF PRQJECT(Check all that aDnhr) 4M WOi'IC +ITrHORIZED UNDER PERMIT ate'.
<br /> Q i.TANZt'INSTALLATION OR REPI.ACEMEtv3T. (Nunn nr Datc):
<br /> ❑ 2..111 INSTALLATION OR REPLACEMENT
<br /> SF)MP INTSrAI:LA.TION OR REPLACEMENT
<br /> ©_4.UNDER DISPENSER CONTAINMENT'INSTALLATION OR REPLACEMENT
<br /> 0 5.OTIMR
<br /> ----...- — ---=-- .WORK-WORIiBEING.CERT-CERT — -- _..-
<br /> _
<br /> Wd'
<br /> R ,
<br /> / 'n n
<br /> ^Y.` a'•?s1 adye'rM'e+,y.2*�r5+..d:••ca. +3+."c.x +,�' +.w .r+4.;w t y'9'�"� �',-^b s^w #Z s..r �C!at}°i c+.�•--
<br /> � .,�,c x i..y�,ea.°�`�"wa'�z`^�"`���'a.� 'j'�,�t .�.'.�l ��� � . �i a YF►� m�-x yew�..*�'..��. �",� 5?�..• ' -. s�
<br /> NAME OF CO R O P TALLA ON/MODIFICATION 48''
<br /> CONTRALTO LTCEATSE# affib ICC•CERTTFICA ON' s, arc
<br /> ha
<br /> ,'3'. "'"i" �— — !t,f �3u"��'�.` ;`�.� "a' ��Rk� +�+�.��,.s" .:s'- r.�,�-.�*�+w�.*a�=v.="""a i,�,f, ` '� k�`w'� c�°. �'r�•':u *'.�"K..'��nn
<br /> I certify that the information provided herein is true,accurate,and that the following i �nditions have been satisfied:
<br /> The installerbasmetthe requirements set forth.in 23 CCR°§271S.:subdivisions(g)ani I)_``.
<br /> The underground storage tank, any primary.piping,and any secondary containa r, t was installed according to applicable
<br /> voluntary consensus standards and any.,manufacturer's written installation Instruction::
<br /> All work listed in the manufacturer's installation checklist been completed
<br /> The.installation has been.inspected and,approved by the lo a;envy,or if requirred b; tl to local agency,inspected andceztified
<br /> b are ' lured rofessional en .. eer havin education and'e iencu with undereroun, sroraee tank stem installations.
<br /> SI OF TANK OWNER
<br /> OR OWNER'S ACsENT DA asa PHONE a�
<br /> ass — 4su.
<br /> CERTIF¢R'S N 4M$ ne) CER 'S T[ITZ
<br /> OF S EMPLOYER(DBA)`' '9& CERTIFIER-S RELATION Si i'TO.TANK OWNER aen
<br /> '. El,L TAINK'OWNER- EJ';2 TA3QI:'OPER 0.TOR
<br /> 3.CONTRACTOR ❑ 4.PROPERTY OAVER
<br /> �] 5.OT ,iGEi`rr OF T.0.NI:OWNER"
<br /> IIPCF UST-C Rev.(I2tS007)=12 wig x.unidocs ox e
<br />
|