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• DRli=lc'J oR00fi6:A (UP) FORM <br />umnit-MaROUND STORAGE Ti ANKH - NSTaLLATiVON <br />CERTIFICATE OF COMPLIANCE (ot)epage per !anx) <br />Palo <br />of <br />1. FACILITY IDENTIFICATION <br />BUS! NESS NW.4EiSam..& ria FA=TY PIA. -'E .^.: 0SA - Dorn-. gulf ra As, <br />'Adie 437$ 46L S.tjFF <br />� <br />vazxe <br />47s <br />A006ESS <br />:.^,care �'�z�s:Ty PA2�t,J�sY ST®tl�Tg� C.A cIS�14 <br />� <br />rACUTY 10# <br />I I I I I 11 1 i <br />I' I TANK I Q' <br />°n <br />11. INSTALLATION <br />(Check all that apply) <br />F%-, 'The installer has been trained and certified by the tank and piping manufacturers. <br />I " <br />418 <br />J <br />1 <br />I n The Installation has been inspected and certified by a registered professional engineer having education and <br />479 <br />I experience with underground storage tank installadons. <br />I <br />I[,� T"s installation has been inspected and approved by the Unified Program Agency. <br />I All work listed on the rnanufacturees Installation checklist has been completed. <br />481 <br />482 <br />ne installer has been carti{ied or licensed by the Contrat—Aors' `Mate license Board. <br />483 <br />The underground storage tank, any primary piping, and seconudai y containment was installed according to <br />� <br />applicable voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified:(� ���uA.,�� �,,� F N E U'5'rt ;moo e -r_ �. f >J 6 s <br />A N b I <br />i otjCToetti3C- `J yS"r€'M <br />I <br />i <br />t <br />I <br />1 <br />! <br />I <br />i <br />Ili. TANK OWNERIAGENT SIGNATURE <br />J <br />J 1 certify f4pt mo information providod herein is true and accurate to the best of my knowledge. <br />SIGN' T'^B. ^.tr'd, ,•- GENT ' CATE <br />`&` <br />NAME OF TA wNEPJAGENT (Fn.nt) 4411 I TITLE OF TANK WNERIAGENT <br />Q6 <br />I 641 f' 8 51U / lid <br />UIP FORM (1/2044 Version) 1 UPF_LAC-c 08_USTC <br />THE CUPAs OF LOS ANGELES COUN TY <br />