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Jan 10 07 03: 03p Elite Iv Contractors Inc 2094618342 p. l <br /> Ak <br /> �� — <br /> F UNIFIED PROGRAM CONSOLIDATED FORM <br /> I <br /> TANKS <br /> N <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE 1 <br /> i (DNB page per tank) <br /> vase _ M <br /> 1.FACILITY IDENTIFICATION 5r2/'r w'l �&q <br /> BWINEGS NAME(SameMFACILITY NAME or DBA-Dong BualiNea Ae)C� � f ✓I � <br /> ADDRESS(rarloul uae arNY) <br /> 3 3 ,41' 1iq V, 9 9C� a . <br /> FAORIT 1) 1 TANK IO# <br /> o X39 <br /> II.INSTALLATION <br /> (Check all that appy) <br /> Fad The installer has been trained and certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> Er All work listed on the manufacturer's installation checklist has been completed. <br /> Q The installer has been certified or licensed by the Contractors'State License Board. <br /> 171-� The underground storage tank,any primary piping,and secondary containment was installed according to <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br /> work being certified: <br /> I <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> I<nmM#u1Me mlgnnetign prodded Mroin h bue oiM acMab to iM1e Ontef my ErowWge. <br /> SIGNATURE OFI � � DATE <br /> NAME OF TANK MNMAGENT(M*d) TRLE OFTANK OI NERIAGENT <br /> Sa-rocl rlh �-��rC�. le <br />