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Nov • 14 . 2008 3 : 55PM LC SERVICES No •5217 P , 2 <br /> NIFIED PROGRAM CONSOLIDATED;&Nr <br /> TANKS <br /> UNDERGROUND STORAGE TANKS—INSTALLATION <br /> CERTIFICATE OF COMPLIANCE xx ng pu amk <br /> nay �t <br /> L FACILMY IDENTIFICATION <br /> BDSJIVE5SN.�IttE eR.nean PaCaAlll'TLidIPIapM-Oww Bwy�.,.{,.1 ��1 �L 3 <br /> ADDRESS--- ,ad��l ~• LNl 4-6 <br /> F.ACB,ITI'lDe <br /> U.INSTALLATION <br /> (l"6eJ:aR that apply) <br /> The installer has been trained and ceatif ed by the tank and piping manufacturers -8. <br /> I y The installation has been inspected and certified by a registered professional engineer having education and experience 4-9 <br /> with underground storage tank installations, <br /> [� The installation has been inspected and approved by the Unified Program Agency. aV <br /> All work listed on the manufacturer's installation checklist has been completed. 41 <br /> The installer has been certifiod or licensed by the Contractors' State License Boatel, a: <br /> LJV The underground storage tank,any primary piping,and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being oerufmL <br /> In TANK OWNER/AGENT SIGNATURE <br /> I eettify Wit We iafomiawa px ided hm is hue and accwate to We beat of my tawwte*. <br /> SION.akil ttpAWMANER.AGENT D.�TE iva <br /> r yC� <br /> NA IE OF TA M OTI NER JiGENT�priutt 4H' TITLE OF T-kM C NER.AGENT 4F0 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />