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Jan 29 08 09s56a Elite 'v Contractors Inc 209461 42 p.2 <br />i <br />UNMED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page of <br />L FACnXrY IDENTIFICATION <br />s <br />BUSIMSS NAAC (same as FACRXrYNAW DSA—Do' •g Buai^ ' Az <br />t <br />3. <br />ADDRESS (Fortoca =only) <br />FACILITY iD# <br />T ID # <br />477. <br />l <br />II. INSTALLATION <br />(Check all that apply) <br />e installer has been trained and certified by the tank and piping manufacturers. <br />41. <br />The installation has been inspected and certified by a registered professional engineer having education and experience a's. <br />with underground storage tank installation <br />480. <br />The installation has been inspected and approved by the Unified Program Agency. <br />nst. <br />fj""A l work listed on the manufacturer's installation checklist has been completed. <br />4M.e <br />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 asr_ <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />long <br />M1,11tUENE <br />11=: <br />2008 <br />q <br />�'iC�' ��(i 'dG i �- 3 / � <br />SAN U'N COUNTY <br />ENviRoNMENTAL <br />HEALTH DEPARTMENT <br />Vh,� <br />M TANK OWNEWAGENT SIGNATURE <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />st UREOFT OWNEWAGENT <br />DATE <br />494. <br />�44AME OFT WNER/AG nt ass. <br />CL %)�' re;.. <br />TITLE TANK OWNEIUAG�—� 4• <br />%' r <br />u <br />UPCF (1/99) Hwfwre-c -1/2 http--//www.unidemerg Rev. 02/16/00 <br />Ist <br />