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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />TANKS <br />(one page per tank) <br />Page _ of _ <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) <br />I. FACILITY IDENTIFICATION <br />II. INSTALLATION <br />(Check all that apply) <br />❑ The installer has been trained and certified by the tank and piping manufacturers. <br />❑ The installation has been inspected and certified by a registered professional engineer having education and <br />experience with underground storage tank installations. <br />❑ The installation has been inspected and approved by the Unified Program Agency. <br />❑ All work listed on the manufacturer's installation checklist has been completed. <br />❑ The installer has been certified or licensed by the Contractors' State License Board. <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to <br />applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br />work being certified: <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 />SIGNATURE OF TANK OWNERIAGENT <br />DATE <br />NAME OF TANK OWNER/AGENT(print) <br />TITLE OF TANK OWNER/AGENT <br />CLIPAFORMS (4/99) Formerly SWRCB Form C <br />