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Dec l�3 07 08: 37a Elite Iv Contractors Inc 2094616342 P. <br /> .. 0 <br /> ---------------- <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (onc page pertank) <br /> Page_of_ <br /> L FACIIITY IDENTIFICATION <br /> �. <br /> BUs—.FSSN hE(s euF ANG2.116A-pall m< As) n_ ]L <br /> 1 �Y/ 1 lWl �f �/F <br /> ADDRESS(Fmmalueeany 1 �• )/fit . JI `. I 'Ii.( %c �✓ <br /> FACILITY IDN l TANKIDN <br /> O` D.INSTALLATION <br /> (Check all that apply) <br /> a <br /> e installer has been trained and certified by the tank and piping manufactmeZm <br /> The installation has been inspected and certified by a registered professional engineer having education and experience <br /> underground storage tank installations. �. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> MI. <br /> 9/�A11 work listed on the manufacturer's installation checklist has been completed. <br /> �he 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 083 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> 41aud Aot <br /> M.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is We and actuate to the best of my knowledge. <br /> ae<. <br /> SIGNA G <br /> . at5. T TANK WNER/A ass. <br /> ANK f�IER/AG print) <br /> UPCF(1199)ffwfw -c-12 hltp:8www.mudoesorg ��•OutG/0a <br />