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Feb 01 13 07: 41a Elit IV Contactors _ 12094 6342 p. 2 <br /> s P + - _ .t. e L ,c a Pv- a •w4• ..•_ <br /> � I °� . .�W�.. - 'rk a �• a . ° � P" °''P it�+ 1 <br /> .. - . •' VNIFI"ED PROGRAMCONSOLIDATE?1 tINI <br /> UNDERGROUND STORAGE.TANK <br /> ' CERTIFICATION.0F INSTALLATI® T/11 ,IZ} CATIC?N ^ <br /> els '.9 <br /> FACn=ID#(Agency Use or,fy) r <br /> I311$TNESS NAME{S�ns t�FAC73.YIY NAME DBA—Doing Bucines AsJ <br /> 3. <br /> BUSINESS <br /> 194' <br /> z <br /> TYPE OF PROJECT(Check ail that a6nly)- 4na won� MORiZED UNDER PMMT 483b. <br /> ® I.TANK INSTALLAMON OR REPLACEtv1k"�i1; (Num<er .i Dee): <br /> 0 2:PIPJNG INSTALLAnON OR REPLACEMENT <br /> 0 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDBR DISP NTAEVMENT INSTALLATION ORREPLACEi +i'T <br /> 5:OTHER <br /> DESCRIPTION OF WQjZK BWG CERTIFIED: <br /> cvt nff'�C' <br /> ce o -+hb`(Xo �n5 ' 61t`d 4t, <br /> frx'I WCO la.1 e tcmt f X2 <br /> NAME OF CONTRACTOR WHO PERFORM INSTALLATION t MQDIFICAn0N A <br /> CONTRACTOR LICENSE# axzb.AA ICC CERTIFICATION# asx� <br /> I certify that the information provided herein.is,trae,.accua-ate,-and-that.the foilowing•crint ifoas have beeia`satisEed: <br /> The installer has met the requirements set Forth in 23 CCR§2715,subdivisions(g).dud.(h). <br /> •. . T1ie.underDrvund. Storage.. an r <br /> Y p tma;Y. p?pings a>zd:any Se dal c9a¢t&zmment V is installed-according to applicable <br /> �viilimfaiy conseiiji standards a id any manufacturer's w>atten installation instructions. <br /> All work listed in the manufacturer's installation checklist has been completed. <br /> ® <br /> The installation has been inspected a a?I+�.approved.b. :th_e.locat a en 1••, <br /> Y g cy,.or:Kiequirred.by..tiie Ocal-agency,iiaspected and certified <br /> _ regi rofessional''eri'`s3eei$avui^educatiion:and.ex en e�+ith.unde onnd-s:0 tie taink.s stem-installations. <br /> IxNA I URE O (3 'S <br /> DATE.. <br /> AGENT - <br /> _.... a <br /> >a: <br /> •` ��� '� PHONE" axe. <br /> _ i. <br /> _._:Gj R ' IER-S NAMH(Fint) ass CERTIFIER°S 4e5. f•. <br /> NAME OF_CERTIFIER'SEWLOYER(DBA) +es CERTn12 [tSONERRELATTOIdSMP ( 7' NW . sev <br /> p i.xANx ovvNER ?.xANIC bPERAxOR <br /> PRO5.0719023K.- <br /> ISERTY OWNER i <br /> _.._...-___.._...... -..__I:.. <br /> 0r ER <br /> ,.,1UFGRUST-G-IPI , ; <br />