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Nov 08 06 06:08p Elite Iv Contractors Inc 2094616842 <br />p.2 <br />�— UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(one page per tank) <br />L_ Paye _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Bminas As) <br />Su h e r er v-7 <br />ADDRESS (For ccalu oNy) <br />7 c E. C t Q r S 7—cA Z�T nJ 9 Z D <br />FACILITY Ipp 1 1 TANK ID if <br />1-171 <br />II. INSTALLATION <br />(Check all that apply) <br />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 />;1 The installation has been inspected and approved by the Unified Program Agency. <br />All work listed on the manufacturer's installation checklist has been completed. <br />XThe installer has been certified or licensed by the Contractors' State License Board. 4, 13J C -- to * f f 4.z <br />Ii 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 />R A X �iu 5 7; //,,,I 6� <br />o u $ C o <br />III. TANK OWNERIAGENT SIGNATURE <br />I cer4ty OW" information pmvxleIV6rt 11 I— and 3—te to the beet o1 my lanwleage. <br />SIGNATURE OF KOWNE AGENJ' <br />DATE <br />NAMEF TANK OWNER/AGENT (print} <br />"Pe 7'— <br />TITLE OF TANK OWNEWAGENT <br />S CAL <br />