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c <br /> i TFTF,D PROGRAM CONSOLMATED FOIW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(5a .m FACILITY NAME w DBA—Doing Business As) r <br /> eo <br /> ADDRESS(Far 1«d use any) <br /> 476 <br /> 35 ) TOCAc-Tor.1 <br /> FACILITY ID# t TANK ID# 4n <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 4T6 <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 479 <br /> with underground storage tank installations. <br /> sao <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> Oat <br /> EK All work listed on the manufacturer's installation checklist has been completed. <br /> �,/ 4az <br /> Lid' The installer has been certified or licensed by the Contractors' State License Board. <br /> ai/lbe underground storage tank,any primary piping,and secondary containment was installed according to applicable 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> M. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> IGNAT F TANK O)'NER/AGENT DATE /0 4" <br /> NAME TANK OVfNEpjAq.ENT(print) 4as TITLE OF TANK OWNER/AGENT +se <br /> UPCF(1/99 revised) 177 Formerly SWRCB Form C <br />