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1 UNIFIED PROGRAM (UP) FORM <br />I <br />UNDER GR ND STORAGE TANKS a 1NS'I ALLATION <br />CERTIFICATE OF COMPLIANCE Ione page per tank) <br />Pepe 3 of 3 <br />i. FACILITY IDENTIFICATION <br />E BUSINESS NAME Isom. a, FACILITY WJAE m osA - Dano ausi au al <br />31 <br />IjAe--t TKe Sox *R 43741QV&CAt-ST41FF <br />rADDRESS <br />10858 T2.,, 4-ry CA 9520 <br />476 <br />FACILITY tD* I I I I I <br />I I I I I I fI TANK tG A <br />4» <br />II. INSTALLATION <br />(Check alt that apply) <br />Installer has been trained and certified by the tank and piping manufacturers. <br />476 <br />,20�'-The <br />I <br />❑ The installation has been inspected and certified by a registered professional engineer having education and <br />479 <br />I <br />experience with underground storage tank installations. <br />[ The installation has been inspected and approved by the Unified Program Agency. <br />460 I <br />All work listed on the manufacturer's installation checklist has been. completed. <br />I � <br />491 <br />The installer has been certified or licensed by the Contractors' State License Board. <br />� <br />The underground storage tank, any primary piping, and secondary containment was installed according to <br />da3 <br />f applicable voluntary consansus standards and written manufacture) s installation procedures_ <br />Description of work being certified: ( N S TALL A Tt a N O F N e w V� TS r -j e L- L I N e S <br />a N 0 1 <br />V C <br />1 <br />I <br />I <br />1 <br />1 <br />I <br />I <br />III_ TANK OWNER/AGENT SIGNATURE <br />I cartiiy Ihat the information provided herein is true and a" -urate is the gest of my knowledge - <br />/"I <br />ISIGNA E TA NE AGENT DATE <br />a54 <br />1 to % iId, e <br />NAME OF TAAk OWNER/AGENT (print) 485 TITLE OF ANK OWNERIAGENT <br />466 <br />p t top 3 S 4� ri'K ref E l Ca -a -p— A c. Typ- <br />OFFICIAL USE ONLY I DATE RECEIVED I CUPA <br />UP FORM (112000 Version) <br />THE CUPAs OF LOS ANGELES COUN„ <br />PA <br />PECTOIR <br />UPF_(AC4: Cfl_USTC <br />