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Oct 23 07 03: 00p Eli— Iv Contractors Inc 209461r'g42 p. l <br /> UNVIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (Ona Page Per tank) <br /> Page <br /> L FACILITY IDENTg'ICATION <br /> 13USINESS NAME(Sone u FACUTY NAME or DBA-Doing Basin=A,) <br /> i <br /> ADD <br /> RESS(Fw1n�,iux�ny) ,j 5X L`t:)� 3--7 <br /> 476. <br /> FACII!'TXID# .�vL': Kkr� C <br /> 1 TANK ID# <br /> �.7Z lj 472. <br /> II.INSTALLATION <br /> (Check all that apply) <br /> [] The installer has been trained and certified by the tank and piping manufacturers. 476 <br /> The installation has been inspected and certined by a registered professional engineer having education and experience 479. <br /> with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Pr 48o <br /> ogram Agency. <br /> [� All work listed on the manufacturer's installation checklist has been completed. 481. <br /> Q The installer has been certified or licensed by the Contractors'State License Board 462. <br /> LJ The underground storage tank, any Primary Piping, and sewn <br /> voluntary conse'sus standards and written manufacturer's installats. <br /> ion pr ®t was installed according to applicable 483. <br /> Description of work being certified: <br /> ����-�� ��-<'-�.,..,�CI.....;� �mow, f-��a n•�:�-t r-�;,a u aare�s <br /> r _ <br /> l _ <br /> IIL TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN URE OF TAN O <br /> 484. <br /> DATE <br /> AbfE OF TANK O R/A, `U 3 t'1 <br /> .._� 465. TITL&,01`TANK OWNER/AGENT 436. <br /> UPCF(1/99)Hwfwrc-c-12 <br /> http://www.unidomorg <br /> Rev.02l16/110 <br />