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09/26/2002 14:40 FAX 425 251 8782 BARGHAUSEN Z002 <br /> UNTFIF.D PROGRAM CONSOLIDATED FORM ,1, <br /> UNDERGROUND STORAGE TANKS —INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> Pageof <br /> I.FACILITY IDENTIFICATION <br /> 3. <br /> FADD�RESS(�,�..,Y) <br /> NAME(Sad>_pnCa."N' a o<ona-po1,Pv' da M) <br /> asoline Loc.No. 135) 476. <br /> 3250 West Grant Line,Tra ,CA t. TANK ID A 1 4n' <br /> FACILrfY IDN <br /> II..INSTALLA'fION <br /> (Check eat that appy) <br /> 4]6. <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 experience <br /> arg, <br /> with underground storage tank insLallations. <br /> 480. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 4s 1. <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 4az <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 <br /> as- <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> TII.TANK OWNER/AGENT SIGNATURE <br /> I gmify that th ormarion provided herein is true=d accurate to dtc best of my knowledge. <br /> 484. <br /> SIGNATLE K AGENT DATE <br /> 0 0-;� <br /> NAME OF WNER/AGEN'r(print) 4R5. T TAN OWNER/AGENT Ms. <br /> ❑PCF(1/99)Hwfwrec-1/2 hup://www-uuidom.org Rev,02/16/00 <br />