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Mar 22 12 08: 36a Elit V Contactors 12094 342 P. 1 <br /> UNWED PROGRAM CONSOLIDATED IRM a <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MOE I "CATIO 2 ' 2012 <br /> (One form per project.) <br /> a � <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) >. <br /> BUSINESS NAME(Same as FACNAME or DBA-Poing Business As) 3. <br /> 1 <br /> rlid <br /> BUSINESS SITE AD RESS -, '03. C — 104. <br /> 1�4 <br /> rU <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check a(I that aooly) 4S3a• WORK it U 14ORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number o Oate): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> (OTHER <br /> DESCRIPTION OF WORK BEING�C}E.R�T�IFI�E`D:: a93C <br /> 1IS�1 � � �i^n 1'��r�Ef cY'�..tJ�L^ �'"' _ �� �r�F`i1 bk:�''^.�t'I'F ��LL'�;rJ.t:!. .I.�.;��" t•'ti'`k-� ��tt/ �6.-?� 'j; <br /> �, 5 ('��ti ��-°(v"' )) j ,.•JJ tt � ��,� ., ,.. '1:. �. '( •:r ;.� {. '4• �✓ r1 i,.��" s.`.J•r"r��'�' <br /> f: `�'.J' 'i �:► t �T'E- (iL`^� 1Jti 3". `r. rfil lilt���1 t f r'" �FZ/r t Ir� "V ° 4C.�U+ <br /> A. 1\_ <br /> ZIP <br /> l,,t:El�� F� - ' 'fit! t L "iGtl ��C�.`' .J ` , 5 <br /> 3� J t EL `^ \J f� '�C C k'C•. lrl`' P=•,. !i`S�{h-t e41, a/ 7�+�' <br /> 1 - J <br /> 2 � `rLJ Ei v` <br /> ,F ,� �i •� r , r' � art �' �;j^ /�;, iPA <br /> III. CONTRACT INFORMATION . .% <br /> NAME OF CONTr R O PEE�tF RIAED INSTALLATION/MODIFICATION 482x <br /> CONTRACTOR L CENSE# ,, 40b_ ICC CERTIFICATION# 42a' <br /> ' d .n6"%. /t1C.' ! - <br /> -z-IV. CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following c nditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)anc.( ). <br /> • The underground storage tank, any primary piping, and any secondary containmei 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 installation has been inspected and approved by the local agency, or if required 133 the local agency,inspected and certified <br /> by a registered professional engineer having education and experience with under .ou.1( :;toraae tanks stem installations. <br /> SIGNATURE OF K OWNER OR WNER'S AGENT DATE .4"• PHONE !�l 487 <br /> � •� s � i„EF't.�L.. '�i ' =,,��— t( `.i'L'/ ) °fir��,(Jc^-�"�--, <br /> CERTIF 'S NAM (print / 485 CERTI`1 'SfTITLE: 485. <br /> ,i , - a-Y:A--, <br /> NAME OF CERTIFIER'S EM PLO ER(DBA) 488 CERT S RELATIONS 'TO TANK O WNER 489' <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZE.0 kGENT OF TANK OWNER <br /> UPCF UST-C-812 Rev.(12/2007) <br />