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L, FI EDP ROG RAM CONS OLIDA TEL )RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page of <br /> WRP. , . <br /> ADDRESS(Forlocal useonly) 476 <br /> FACILMID# $a '. 4I TANK IO# 477 <br /> 7experience <br /> (Check all that apply) <br /> installer has been trained and certified by the tank and piping manufacturers. 478installation has been inspected and certified by a registered professional engineer having education and 479 with underground storage tank installations. <br /> I The installation has been inspected and approved by the Unified Program Agency. 480 <br /> All work listed on the manufacturer=s installation checklist has been completed. 481 <br /> 4� The installer has been certified or licensed by the Contractors =State License Board. 482 <br /> 3r The underground storage tank, any primary piping, and secondary containment was installed according to 4M <br /> applicable voluntary consensus standards and written manufacturer=s installation procedures. <br /> Description of work being certified: <br /> 17�c - 4�s mtz r y s <br /> r rg �> rANre oye14 "14� ��rrNar�t <br /> 1 certify that the information pmvided herein a two and acarate to the best of my knowledge. <br /> SIGNATURE 1'TANK.0DATE 4e4 <br /> S l b 2�v <br /> OPT`ANK 01MER/AG T(print) 485 —TANKOWNE AGENT 486 <br /> V� <br /> n Co- <br /> PCF(1/99 revised) ,... ..,r Formerly SWRCB Form C <br />