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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3 <br />ADDRESS (For local use only) 476 <br />10$5-8 Trlh-,�arl�wa ocin� C� gs210 <br />FACILITY ID# <br />3 <br />I <br />I TANK ID # 477 <br />II. INSTALLATION <br />(Check all that apply) <br />47x <br />The installer has been by the tank <br />trained and certified and piping manufacturers. <br />The installation has been inspected and certified by a registered professional engineer having education and experience 47' <br />with underground storage tank installations. <br />axu <br />The installation has been inspected and approved by the Unified Program Agency. <br />axl <br />I� All work listed on the manufacturer's installation checklist has been completed. <br />axa <br />The installer has been certified or licensed by the Contractors' State License Board. <br />87 <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable 4 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />I ` <br />�pu�•!�i �Cr�ti� 1.0+'V1MuhlCc���3►�S VI—�—= <br />1 <br />-'rCpIZP �Dard• �'o�ci 5{�(� rQ���rt�clJ Jo f'tCo)►tiLe new <br />'K�d� I r'� oT lOw�rv,vhiCa�,ut.,5 �rc-�,►4Sr <br />do��d• 5av�sorS a5- I <br />`` \ <br />rt 0ww (1i\-1 <br />- <br />by <br />Vaeuuw% s%f re p(QkCXd ttl� �r <br />by z�k�� i�yy <br />III. TANK OWNER/AGENT SIGNATURE <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATQRE OF TANKDWNnER/AGENT <br />DATE <br />b � 484 <br />NAME OF TANK OWNER/AGENT (print) 495 <br />Davtid A <br />TITLE OF TANK OWNER/AGENT 4x6 <br />C6mid'a4a 0,ua V- <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />