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UN WED PROGRAM CONSOLMATF.D FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same u FACILITY NAME or DaA-Doing Business Az) <br /> -AaCD 476 <br /> ADDRESS(Far imst nu only) <br /> 3515 lf�— . F-' arA&Ar. l-4eJV-- t `47T-OCe-TO1j <br /> FACILITY ID# I 1 I TANK ID# 4n <br /> IL INSTALLATION <br /> (Check all that apply) <br /> 479The 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 619 <br /> with underground storage tank installations. <br /> 480 <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> —/ 4et <br /> ERP'*' <br /> j All work listed on the manufacturer's installation checklist has been completed. <br /> 463 <br /> L� 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 a83 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> ,-�)i 5� e h k � l)r.4 iJ 4:—:r rz Li t2 v tJ Lj 0 <br /> � lroelu� I � �A� ��r � veV\A aK4 Q ( et_4v- - L►cv 7i �7 � n� <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 /> SIG TUREO KOWNER/AGENT DATE 2>// 7 DD <br /> 4PME OFT K WN A NT print) aas TITLE OF TANK OWNEWAGENT a8h <br /> I G COJE J/JC . <br /> UPCF(1/99 revised) 177 �.J Formerly SWRCB Form C <br />