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09/26/2002 14:40 FAX 425 251 8782 BARGEAUSEN [A 005 LIST Installation-Certificate of Compliance Form Instructions (formerly SWRCB Farm C) ibis Certification form must be submitted upon the completion of installation or upgrading of tanks Sndlor piping associated with a UST system A separate form is required for each tank or,in the case of compartmentalized tanks,tank compartment. This form must be completed by the UST owner or an authorized representative of the owner. Please number all pages of your submittal. (Note: Numbering of these instructions follows the UPCF data element numbers on the Certification form-) 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 476. ADDRESS-Enter the street address where the tank is located. 477. TANK 1D NUMBER-If the UST owner has assigned an in-house tank M number to this tank,enter that number in this space. This is the same as item 432 on the UPCF UST-Tank Page 1. 478 TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER-Check this box to certify that the installer of this tank system has been trained and certified by the tank and piping equipment manufacturer(s). 479. REGISTERED ENGINEER INSPECTION - Check this box if the installation was inspected and certified by a registered professional engineer(PE). 480. UNIFIED PROGRAM AGENCY INSPECTION-Check this box if the installation was inspected and approved by the Certified Unified Program Agency(CUPA) or authorized Participating Agency(PA). 481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check this box to certify that all work listed on equipment manufacturers'installation checklists was completed. 482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check this box to certify that the installer possesses all certifications and/or licenses the CSLB requires for installation/upgrading of UST systems- 483. APPLICABLE STANDARDS AND PROCEDURES -Check this box to certify that the UST system was installed according to all applicable voluntary consensus standards and manufacturer's written installation instructions. DESCRIPTION OF WORK - in the space provided, describe the work performed. Specify the type and the extent of work completed on this tank system (e.g. installation of complete tank system, installation of dispenser secondary containment, replacement of product piping, installation of turbine sumps,etc.). SIGNATURE OF TANK OWNER/AGENT - The tank owner or an authorized agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 484. DATE CERTIFIED-Enter the date the Certification was signed 485. TANK OWNER/AGENT NAME-Enter the full printed name of the person signing the Certification. 486. TANK OWNER/AGENT TnLE-Enter the title of the person sighting the Certification. (Note: It is mandatory that items 478,481,482,and 483 be certified. In addition, you must certify that the inspections in either item 479 or item 480 have been performed.) UPCF(1199)ff vfwrct-212 http://w .a.idoo.org Rev.02116100