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Aug 31 09 08:58a Elite IV Contactors 12094616342 p.2 <br />4 is <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION MODIFICATION <br />1011P.form.perpro <br />jec;). <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME {Same as Fod1hy Name or DBA - Doing Business As) 3. <br />BUSINESS SITE ADDR939- 103. CITY <br />TYPE OF PROJECT (Cherkall thm armly) '�1 WORK ALTHORlZED UNAER PERMIT as3e. <br />❑ 3. SUMP INSTALLATION OR REPLACEivI1;NT <br />4. UNDER DISP�1SER CONTAII�TMENT INSTALLATION OR REPLACEMt:A1T <br />5. OTHER <br />DnCRIPTI ON OF WORK BEING CERTIFIED: <br />wpdvo ail jli�u lot j 0% E U <br />I A I A t <br />NAME OF <br />CONTRA ;6 6C <br />pCENSE # 06 <br />CC <br />I <br />1 <br />cr- & �.�R _ 4n � <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />• It installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />• Th dMeround 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 4*tstallatjon has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by0egistered Professional engineer Navin education and EERerience with underground storage tank tem installations. <br />SI OF TANK OWNER OR OWNER'S AGENT DATE 484• 1 PHONE 48" , <br />I& <br />RkffS N,�WAin,) CERfDjk-ST=: 486. �- Ircl V"d be-( <br />NAME OF CERTIFIER'S EMPLOYER (DBA) `'n'CERITFIER'S RELA*noI,%,sw To T.ANKOWNER 489. <br />I. T-kNK OWNER 13 2. TANK" OPERATOR <br />3. CONTRACTOR 0 4. PROPERTY OWNER <br />0 S. OTHER AUTHOR= AGENT OF TANK awmF-R <br />UPCF UST -C Rev. (122007) - L2 wwwxnidomorg <br />