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Jun313 13 .09:03a Elit IV Contactors 120946 342 p. 2 <br /> J <br /> �y .( <br /> ' O�wV 1YT1W.i 0v d;s <br /> UNDERGROUND ST012A.GR TA .j%. <br /> CERTIl�'ICAs TiON. <br /> 1 OF <br /> IWSTALLATIONN/A 001KCATION J U N 1.3 <br /> 2'0 13 <br /> (Ona form pcw projecL) <br /> FACIL T Y ID#,(Agency ase 0*) _ <br /> BUSINESS NAME(s w pAcIIaTstwuseerD$A^nafivEustaeffiAa) _ <br /> \ _ 3. .. <br /> BUSII�}�ESS+S'I}TEADDRtESg3}� }�•�r J �! !�. Cir144, <br /> — <br /> TYPE OF PROJHCr(Cbeck •aUL FVOF.K JJ1T30RI2BD UNDI1t PF1tA�IIT ses� <br /> ® 1.TANK DWALLATTON ORREPX.AMAENT' (Nast bi or Date): <br /> 0.2.PIPING INSTA-LLATION OR REPLACEMENT <br /> •El 3.BUMF'INSTALLATION 0jrRMjACM&ff <br /> (} <br /> 4.CINDER.DISPENSER CONTAINi A T INSTALLATION 01 REPLACEMENT <br /> S.OTTIEI2 <br /> D .C RiPTION OF WORICEEIIIG CRI�IED: <br /> 40a <br /> 1 (qct 113 <br /> d.6 <br /> NAME OF,CONPRACTORWHO PWORM WTAL[aq.TION/MODIFICATION' asza <br /> u <br /> CONTRACTOR LICENSE# M <br /> .... . �,S?.1� ._&•91.1..���-!_�7. __ �CBR1�k7CA1TQN#• .. •. asza. <br /> f3"t a�the anfo mataomprovide&b.erein-is ft"ccurat"nd-that•the�follo%ing-c,)Ig ltfions-have-bpen satisfied: <br /> ®_. The instatiei hag.. ItSlaa.x�quirementcsetfottli-in,23GR€§27I5;subdi�!isions.¢gj and(lid. <br /> • Ttie.gncierground tdraga.# , aiiY. tn?o?$�3'.:P?P .fid.aray secondary'iotrtair�npgn, us insta'Ited acGordang to_applicable <br /> vo untary consepstrs.stata , sny menu a wnten Ins. Iitton:lnshuctzons, "` ._ <br /> • A0 work listed in them man .. . eias instaljatiori cheeklistltas kieen= r ►letest. <br /> „®...::. atstaUation.has:been-.in'spected and,approged byagency;iir`Jf Mquireci by h local aged <br /> c ,inspected anis certified <br /> Bred feshional•en ineerha ' education snd erlence with under ound..tr ;u a tanks stem installations. <br /> SIQN' <br /> .. WNER'�;AZfRN'i".�7._.__ :..,......_..... :..I�A'PIr...._._:.:.:.. . ..ataM • <br /> a17. _. .. <br /> .. .. 'PHON1<'" _,.. rp .Fj�q•;2] <br /> {Pdni3G <br /> . .. .• •CERTIFYLR'S <br /> TrrLE 49Khe <br /> 1 <br /> NAIvJE.OF 6ERTIFIER'S OYER...•EA • <br /> { ss <br /> Cls�T'iT'l�lt�'RBLA: ONTI Sx•FILf•'i ''.CAN2&4� <br /> ,;1.V[?_,5 <br /> t.TANK OWNES. . C 2.°TANK 6P.ERATOR <br /> �,. <br /> 3.COIITRACTaat [ PROPERTY 6%NER <br /> _..... . 5.omm--';k' RIM jIi eTLDF. <br /> TAM.OWNER_: <br />