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UNIFIED PROGRAM (UP) FORM <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE lone page per lank) <br />Pao 2 a <br />1. FACILITY IDENTIFICATION <br />BUSINESS NAME tSr» as FACIUTY NME at DBA - oxo avd:ess As! <br />*i- St+J F F <br />3 <br />A WC s N TKE Sox 4374 V a c.4— <br />ADDRESS <br />10858 7-&.Ni-ry PAa.v—w^y Sracw-r-j, CA 95219 <br />4�e <br />FACILITY IDrr <br />` <br />' <br />TANK IO # <br />°n <br />I <br />I <br />11. INSTALLATION <br />(Check all that apply) <br />2 -The installer has been trained and certified by the tank and piping manufacturers. <br />ua <br />I ❑ The installation has been inspected and certified by a registered professional engineer having education and <br />47s <br />experience with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />4B <br />All work fisted on the manufacturer's installation checklist has been completed. <br />;ss <br />installer has been certified or licensed by the Contractors' State License Board. <br />462The <br />381 <br />The underground storage tank, any primary piping, and secondary containment was installed according to <br />I applicable voluntary consensus standards and written manufacturer's installation procedures. <br />I <br />Description of work being certified: j N STAt.L ATf a rJ d F N E 4J v Fv e L t N C S <br />A D <br />I <br />l <br />I <br />I <br />I <br />I <br />f <br />111. TANK OWNER/AGENT SIGNATURE <br />I I certify that the information provided herein is true and accurate to the best of my knowledge. <br />I <br />SIGMAM NE AGENT <br />DATE <br />s84 , <br />NAMEOF TANK WNER1AGENT (print) 495 <br />TITLE OF TANK OWNEFVAG ENT <br />36 <br />I YN/LI P 9 '5AA rr#( <br />I �EN� / C.aNT,eACrof,. <br />ONLY I DATE RECEIVED I CUPA 1 PA I DISTRICT/INSP <br />1 �P FORM (12000 Version) t UPF_LACa: 08_USTC <br />THE CUPAs OF LOS ANGELES COUN TY <br />