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Nov 14 07 09:SGa <br />9 <br />Elite Tv Contractors Inc 2094642 <br />0 mho <br />p.4 <br />YYii aluI (. - <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Pageof <br />L FACILITY IDENTIFICATION 0-5195 7 <br />BUSINESS NAME (Same w FACn.rrY NAME or ABA- Doing BuS ss As 3' <br />476. <br />ADDRESS (Fortowl.s —Iy) <br />l� v <br />FACILITY IDS <br />62 <br />t <br />TANK ID # art. <br />II. INSTALLATION <br />(Check all that apply) <br />f 478. <br />installer has been trained and certified by the tank and piping manufacturers. <br />�e <br />e installation has been inspected and certified by a registered professional engineer having education and experience 479. <br />th underground storage tank installations. <br />4ae. <br />The installation has been inspected and approved by the Unified Program Agency. <br />Oat. <br />All work listed on the manufacturer's installation checklist has been completed. <br />452. <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 483. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />scription ofwork being certified: <br />apaz_/ <br />III. TANK OWNERIAGENT SIGNATI3RE <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF T. K O R/i --�" <br />DATE x /)484. <br />NAME OF TANK OWNER/AG (pent) 4R$• <br />TITLE 09 TANK OWNER/AG, 486. <br />M <br />UPCF (1199) Hwrwre-c -112 bttp://www.unidecs.org Rev. 02/16/00 <br />