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G <br /> PROGRAM CONSOLMATF.D FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_or_ <br /> I.FACILITY IDENTIFICATION <br /> r <br /> BUSINESS NAME IS..FACIUW NAME or DBA—Ming Buai..Aal <br /> -Aaao 476 <br /> ADDRESS(Fa1�—mty) <br /> t A4AANl C4nl� 5iOCILTo <br /> FACILITY ID# TANK ID 11 an <br /> IL INSTALLATION <br /> (Check all that apply) <br /> 6]g <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 4] <br /> with underground storage tank installations. <br /> +so <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> agl <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> 432 <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> VThe underground storage tank,any primary piping, and secondary containment was installed according to applicable 4" <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGATU ^TANK O ERh GENT DATE 40+ <br /> g �� vL) <br /> O ANK O ER/AGENT(print) +g5 TIT OF T. NK O ER/AGENT +ae <br /> UPCF(1/99 revised) 177 Formerly SWRCB Form C <br />