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E •Dec 24 14 08t44a Eli Iv Contractors Inc 208461!,;242A <br /> 004616 42A <br /> R E® MED <br /> F! <br /> UN109, l}PROD CONSOLIDATED FORM <br /> 'UNDERGROUND.In'ORAGIC TANK <br /> CERTIFICATION OF INSTALLATION/MO (FICA � � .. ALT <br /> C.Ali A 11Lt`I'�!iN1FCa}iMATYON.r <br /> FAC:II.T 11.?#(Agebcy Uw Only) I,. <br /> �U5EhILS i tJAMI (s.n PAcua'tY AAa E"011A.LWOOau Ann J. <br /> (ill! rwcC . (l ore, cc` ) <br /> IIUSINim S1T1i At31-MM CITY np._ <br /> ATION I M+D!?1 ATCCIN:PI U3EyC[Dl!, GfiTC"T1 ?.I : <br /> (L.IN, <br /> TYPE Ot <br /> ECT <br /> (Check all that emlv) 'r'° WORK AUTI'IORI",r)tnvns_R PLRmrf <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number ar Daft): <br /> ,❑ 2.PIPING IMALLATTONOIL RE-PLACEMENT <br /> Q 3.SrJMP rNSTAY„I,ATION OR REPT.ACIaWM4TT c���1 - )o I ,(, () <br /> ❑ d,IMER,Dr3PF1NBr,3Z GONTAINMI•n�dT INSTALLATION OR RF.Pt.ACF.MENT <br /> S.OTHFSR <br /> ESCRII'I'►ON OF WORK BEING CER llil). d8lo <br /> t1IC:;t �si� 1�� 2.Y1`i�ti't-1Z k_ �' `1 `�iTr �. 1?' 3'!`( Af 1-1'f)fb ►L� �11�� cC1 <br /> t?r n �� ��: a t����.�t_:�;✓�t :�r.. <br /> -- <br /> I . t A MRAC'TOR INFORiVI MO N. . <br /> NAMI:OV CON'IY(AC IM w1101'IMMUR O)INSTAMAT(ON I MOMPICATION <br /> CONTRACTOR LICENSE k �i4b ICC(NRIVICATTON VV aoc <br /> 1 o:ertia('y that the information provided herein is tme,accurate,and that the following conditions have becu sxtixfied: <br /> • The installer has met the requim ments sot forth in 23 CCR§2715,subdivisions(g)and(h� <br /> • The underground storage tank. any pfhnM piping, and any secondary Containment was installed according to applicable <br /> voluntary consensus standards'and any munufacturces written installation instructions. <br /> • All work listed in the manufactur'er'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 certifted <br /> by a registered professional en rinccr having education and ex rkmc with undo round storage tank system installations. <br /> SIONA V OWNER O8odWNUK3 AUI.NI' JAKIT M'• PHONEAr <br /> 4i7. <br /> CFRTtEIYA'S NAM$(Prins) �S CERTjpjrWS TITLEUr: <br /> NAIVE OF CEB.TWIER'S EMPLOYER(DBA) Nb° CERIVIIIA-8 RELK11ONSUIP TO TANK OWNFR °sg' <br /> N <br /> K QWNrP 3.CONTRAGIM p a .PROP OW2.TANK NER <br /> ❑ 5.ars- ,'k AU111ORIZET)AGENT OF TANK OWNER <br /> UP00 uS""I'-C•112 Rev.(12auu?) <br />