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8-22-07;10:23AM;SACRAMENTO EMC <br />1 0 0 <br />;918 925 2816 # A- a <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page of_ <br />51 g" <br />"HR Ow"sy 1f1 <br />p- qg <br />Y. m <br />N <br />Lra'L ,T fij 'R 1.. M-,!­!� <br />BUSINESS NAME(Same a F�MACILrr YNAMHort)RA-DoinglluMn��) J. <br />-7 — E 4irVir4 !3 g Ig 0 <br />ADDRESS (For imi = only) 474. <br />&jqtY-k !7C) 5'r0C-J1<'r44 C q<L <br />FACTLrFY IDN <br />TANK M # an. <br />pig; <br />1 1 <br />-,V 11-1c-1 Eli <br />NOWrj <br />(Check all that apply) <br />479. <br />�The installer has been trained and certified by the tank and piping manufacturers. <br />A04 The installation has been inspected and certified by a registered professional engineer having education and experience <br />wi underground storage tank installations. <br />all. <br />--the <br />2 installation has been inspected and approved by the Unified Program Agency. <br /><11 <br />[�r work listed on the manufacturer's installation checklist has been completed. <br />431 <br />2--<e 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 483. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />)UPI'AC-11 !!�fa*SXV212 iff 17 & —iQ2 Cka,k- VALyt-; <br />1-0/ t n 119r1S6a 01;1 ChRVIZOM 10A1QJZr11A1'f" <br />. ... ............ . ......... <br />won 0 "n <br />54, , <br />e -i4 <br />JR.", <br />I mi 01� <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNA7URFENT <br />DATE <br />If -i-7 <br />NAME OF TANK OWNERIAGENT (print) a5- <br />TITLE OF TANK OWNER/AGENT aaa <br />I- a E W rz V jz- <br />nlllsli(r�,mene-pg -5v43i7aViswZ <br />UPCF (1/99) Hwfwrc-c -1/2 www.unidocsorg Rev. 02/16100 <br />