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Mar 18 10 12:21p Elite IV Contactors 12094616342 p.4 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTWICA.TION OF INSTALLATION / MODIFICATION, <br />One form:pex:project)... _..... . <br />FACILITY M #A <br />( 8encv Use Only) ia <br />BUSINESS NAME (Spree asFocrliryName or DBA -Doing Business As) 3, <br />BusWussrmADDRESS X03. CIT is 104. <br />'L Pi52&6P I CVC. .� <br />�, . �, :.... . __ - - � �-�s � z� '?q.asatr•aaa k:.m�,� xr?ar+w¢.s q�r�em w.t`c:-'�'3. •.�msac. c: ��- sus ^**:.n a.sp,..r•d.:;� ;;.�h ��•k +� r <br />- <br />ME OF PROJECTCck allhaw21V . . PMWORKAUTHORMM UNDER ERIT <br />0 I. TANK INSTALLATION' OR REPLACEMENT: (Number or Dam): <br />® 2. PIPING. INSTALLATION OR REPLACEMFNI <br />Q. 3. SMTP INSTALLATION OR REPL.AC. M -NT 3 F.��� 1 <br />5 <br />❑: UNDER DISPENSER CONTAIIv�NT INSTALLATION OR REPLACEMENT. f. <br />5: OTBIIt � <br />--DESCRIPTION OF WORT: BEING. TIFIEiED:..._.,..._......... - - -- -- ...... _ .._..._..:_ _........:.....—. _.. <br />n. Annulcks S cxQ-1t, crrn <br />CONTR4CTOR LICENSE # 4 FCC CEitTIFIGAT IOAT'# « <br />�... ' ..U <br />I certify that the information.provided herein is true, accurate, and that the following conditions have been satisfied: 4 <br />• The installer bas -met -the -requirements set forth in 23 CCR ¢2715, subdivisions (g) and (h): " <br />• . The underground storage •taxi:, any primary piping, and .any. secondary 'containtnent-was installed .according to applicable <br />-vohmtmy consensus standards and any,manufacturer's written installation•instruei_ions..' <br />P All work listed in the manufacturers installation chectdist has been completed. <br />o The installationhas been inspected and, approved by the local agency, or if required by the Iocalagency, inspected and certifed <br />by a- 'stered rofessional engineerhaving education and experience with and and tank systern installations. <br />SIGNA OF TANK 01 OR OWNER'S AGENT 'DATE, 494• PHONE 4s7. <br />C ERTIFIER'S NAME •i t) ass. CERTIFIER'S.TT£i. e _. 496. <br />NAME OF CEEMIFIER'S EMPLOYER (DBA) 4 CERTIFIER''S RELATIONSFitP.TO. TANK OWNER �s <br />I rA3QK OWNER <br />�t•-•i \�✓ �L.31./���Cl\ t���...�-�-✓ - 'yC��,' . <br />I. -- 0"2. TANK -OPERATOR <br />4��L lL S�-? 1 � � 3. CONTRACTOR :. 0 4. PROPERTY GARNER <br />0 :5.OTHERAUTHORIZSD AGENT OF TANK OWNER <br />UPCF UST -C Rev. (1212007) = V2.wvrw.nnid.cs cc <br />