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Oct 20 08 10:34a Elite Iv Contractors Inc 2094616342 <br />0 a <br />04, TWO) TV I I <br />P.1 <br />UNIFIED PROGRAM CONSOLIDATED FORM -C <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION I MODIFICATION <br />(One form per project) OCT 2 1 20o <br />I. FACILITY INFORMATION SAN JOAQ1 im 9V� <br />FACILITY ID # (Agency Use Only) EN iRO 4 NTA . L <br />H� <br />TMS2 <br />_1iU­S1NESS_N (Same as Facifirv-Noine or DBA - Doing Business As) 3. <br />, 1, <br />I U0,1,11,11 A, <br />vjw)/(_P, <br />13USMEVS-SITE ADDRESS jj 1f1/3 <br />Lo L <br />CITY uw. <br />11. INSTALLATION/ MODIFICATION PROJECT. DESCRIPTION <br />TYPE OF PROJECT (Check all that apply) <br />WORK AUTHORIZED UNDER PERMIT 493b. <br />n I. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />0 2. PIPING INSTALLATION OR REPLACEMENT <br />r7l 3. SUMP INSTALLATION OR REPLACEMENT <br />[] 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />Cl S. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483.. <br />am 4z <br />III. CONTRACTOR INFO.RMATION .. ... ..... <br />NAME OF CONTRA= R 112 ER10 PT J ATION,'MODV:ICATI 48Z& <br />CONTRACTOR JY1459 <br />YN74 <br />[CC CERTIFICATION # <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: <br />a The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). <br />0 The underground 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 check -list has been completed. <br />• The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a registered professional engineer having education and ex erience with underi_rround storage tank system installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 484. <br />PHONE 497. <br />i0r7?OL <br />-a <br />CERTIFIER'S NAE (print) 485. <br />N -Y <br />CER IF 'S TITLE: <br />rl, <br />L\<) C 21 LC2 <br />N_ IER'S EMPLOYE <br />)(DBA) OF CEkY-fe- I )(DBA) <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />0 1. TANK OWNER 0 2. TANK OPERATOR <br />3. CONTRACTOR [3 4. PROPERTY OWNER <br />❑ 5. OTHER ALTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rcv. (1212007) - 1/2 www.unidocs.org <br />