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.lain 19 07 01:42p Flit Iv Contractors Inc 20946 142 P.1 <br />L133 <br />j I UNIFIED PROGRAM CON SOLI5A7E❑ FORM TANKS <br />�` \j UNDERGROUND STORAGE TANKS -INSTALLATION <br />o <br />CERTIFICATE OF COMPLIANCE (0- pageper tank) <br />V - <br />P.Y. <br />t. FAC[LITY IDENTIFICATION <br />BUSYNESS NAME 0m r FACILM NMAE a( ONA . D*49 8rm As) <br />ADDRESS (Fu kx W u o Hy) <br />1 � � <br />Z TANK 1U+ <br />fA[�LITY,�U C p -3 n <br />'f. L <br />t \k t <br />II. INSTALL A11ON <br />(Check aft that apply) <br />The installer has been trained and certified by the tank and piping manufaCturets. <br />The instaltabon has been inspected and certified by a registered professional engineer having education and <br />experience with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />All work tilted on the manufacturer's installation checklist has been completed. <br />V' The instafter has been certified or licensed by the Contractors' State license Sward. <br />❑ The underground sto a tank. any pritrtary piping, and secondary containment was installed according to <br />reg procedures. Description of <br />appficabfe voluntary consensus standards and written manufachx€er s installation prnccd ctG� <br />wo being certified: &L� <br />UI. TANK OWNERIAGENT SIGNATURE <br />I raflYnr..Aan+amon ii. INB are amrm w dr oex oI my t -we 1 <br />DATE <br />SX:NATURE OF TANK cWWFR40OPNT . <br />TRLE OF T WNERIAG <br />7VuWE OF TANK OWNEFUAG f -N7 0-A) <br />