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Nov 14 07 09: 513a Elite Tv Contractors Inc 2094616342 p. 2 <br /> UNWMD PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - .INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of_ <br /> L FACILM IDENTIFICATION <br /> BUSINESS NAME(Same as FACILfTY NAtIE oz P Business As) 3. <br /> R64 <br /> ADDRESS(For local useonly) alb. <br /> 44 Al", kv <br /> FACILITY ID TANK ID# 4777 <br /> a3� <br /> II. INSTALLATION <br /> (Check all that apply) <br /> 418. <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> The mstanation has been inspected and certified by a registered professional engineer having educaiion and experience <br /> with underground storage tank installations. <br /> aso. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> asl. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> ,_,/ 45�. <br /> Lr The installer has been certified or licensed by the Contractors' State License Board. <br /> Theunderground 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 /> Description of work bein certified: � � ,�/, �� ��� <br /> �LrPC�GL . o <br /> _,T <br /> J. 0/� <br /> 3 F H -360- C-CM` bravo bno+- <br /> �J� � X � C a� � ��lt✓�-�v <br /> 'OZ/ <br /> acs. � c {� <br /> aind/ltocOWNER/AGENT SIGNATURE <br /> I cLrtify that the information provided herein is true and accurst to the best of my knowledge. <br /> �,G Nrk <br /> SF- F TATIK O DATE <br /> 4sa. <br /> OFT OVgIER/ ENT(print) ' TITLE OFT R/AGENT 486 <br /> A. <br /> Aild 11LrXL ,4v <br /> UPCF(1/99)awfwrc�-112 http://www.unidocsorg Rev.02/16/00 <br />