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r Dec 15 06 09: 31a E1161v Contractors Inc 2094612 P. 5 <br /> i� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> i <br /> TANKSi <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> i <br /> CERTIFICATE OF COMPLIANCE <br /> i� (one page per tank) <br /> L FACILFTY IDENTIFICATION <br /> 8u5IXE55 NN/E(Samoa FnLLLfiY Eor D9//A-Damp B,e,ross Ac) `J'� <br /> 77 <br /> ADDNE55(Formarueu/A / <br /> ! I /'/CA-1 1 <br /> FACRftY IDp 1 TANK ID/ '� / ' <br /> _1 ' LLL : i <br /> IL INSTALLATION <br /> fChe*all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> t3 The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank Installations. <br /> tS The installation has been inspected and approved by the Unified Program Agency- <br /> In/ <br /> AN work fisted on the manufacturer's installation checklist has been completed. <br /> 3/ The insurer has been certified or frcensed 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 cedified: <br /> / /i,. , , <br /> 7t/L•���Clt1, / � � .1.:11" /.:.6'%l "% !a1.✓f�swl �% �J �UdL% —/L.-C. <br /> i <br /> i <br /> i <br /> I <br /> i <br /> RL TANK OWNERIAGENT SIGNATURE - <br /> I dal/.BB�./omie/oape.+M1./Ie:a'.w w mm m or omor„e hv/E'4F. <br /> SK.W iW1£OFTNIXO AGENT p,� I <br /> INYE OF TANKTNEaIAGflrt`jXV TD{E OF TMKO WAGE <br />