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r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS —INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page�of <br /> I.FACILITY IDENTIFICATION <br /> i. <br /> BUSINESS NAME(sone ea FACHM NAME o,DBA-naia&Business As) <br /> rt d-� je& r 476. <br /> ADDRESS(Par local use dy) <br /> A` a,. — 1r1 k S Gk 477. <br /> FACILITY ID �_ '�' <br /> IL INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> ❑ The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑ <br /> The installation has been inspected and certified by a registered professional. engineer having education and experience 479. <br /> with underground storage tank installations. <br /> 490. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 469. <br /> [ All work listed on the manufacturer's installation checklist has been completed_ <br /> 452. <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 applicable 463, <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> J:ASt4-L0 ttl 6e�ecta-r (V&a Nrle-ss <br /> 99 L 6 �z 000 � �nI 'D r%,-vb z I ,7� W <br /> ����a�� `�"����P~ � ��� ,. cjDS+� � �rl � „�C�►u'?�1�' Dave-A����� <br /> Ar-$3k�or0A r^4cla4 eolj 106 x`111 he- Ar<�' � <br /> /vrtof I-. iStll <br /> 11 <br /> ct <br /> Feub I,—, L0 Pe,,,Wre ct rl kJLId e' 'y4cr Moil 10yJ1C1G11Brl atS A —�Svll <br /> !►F 1--;Aer Ir"3e)5 Aptj p��11 rnq a1J4ttG �I'o�w� L'r �pdcCf G>fernGrt�s: <br /> I III.TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA OF TA O R/AGENT <br /> DATE 984. <br /> /,f h ,/ . — <br /> N F TANK© EWAGEN (print) 455. TITLE OF TANK O AGENT 455. <br /> UPCF(1199)Hsvrwrc-c-1/2 www.unldoes.org Rev.02/16/00 <br />