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Nov 14 07 09s56a Elite Iv Contractors Inc 2094616342 p. 3 <br /> UNMED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAM£(Same as rrACtt.CIY tiA_%ffi or DDA—Doing Biaess As) f <br /> lvmln <br /> ADDRESS(For local use only) <br /> FACILIT "" T O 477,q�J3 <br /> . L! <br /> M INSTALLATION <br /> (Check all that apply) <br /> 479. <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> 0 The installation has been inspected and certified by a registered professional engineer having education and experience 47' <br /> with underground storage tank installations. <br /> meo. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 4sI. <br /> [�All work listed on the manufacturer's installation checklist has been completed. <br /> 4V. <br /> The installer has been certified or licensed by the Contractors'State License Board. <br /> The underground storage tank, any primary piping, and secondary containment was installed according to applicable g" <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified- <br /> 111L TANK OWNERIAGENT SIGNA,TU" <br /> I certify that the information pmvidr d herein is true and accurate to the bestofmy knowledge. <br /> NATUIZE PT.AN -' DATE mom. <br /> r--=- 1113 Q 7 <br /> MEANIE OF TANK OWNS - (priWT mos. TAN[C C1wNErR/AG as[. <br /> UPCF(1/99)Rwfwrc-c-112 http.11www.unidoe&.org Rev.02116/80 <br />