Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS — INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> page \ of <br /> L FACILITY IDENTIFICATION <br /> 3. <br /> B USNEESS NAME(S. .eAc¢.rrrxnn¢eruaA-ooms e�—M) <br /> ` <br /> N -476 <br /> ADDRESS(Forbcal useooiy) <br /> \Aoo 0. �1) cl;% q5 3 b <br /> 4n. <br /> FACILITY IDN t. TANK ID# <br /> II.INSTALLATION <br /> (Check all Oat apply) <br /> 4r . <br /> � The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑'yW// <br /> itstallation has been inspected and certified by a registered professional engineer having education and experience 4A. <br /> with underground storage tank installations <br /> an. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> at. <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 4sz. <br /> The installer has been certified or licensed by the Contractors'State License Board. <br /> The underground storage tank, any Pr��' piping, and i isecondary containment was installed according to applicable <br /> � �' <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> SM,'� � <br /> e t Q,N6 FR ow- Cx ST',r.0 N Ar-`4-5 <br /> 01ST ', 1C q ,SQeMCe ll_S. CN:s Q' ,r.l '.�e\v d�S QtZ«1� cC Oc n,Ap a ,el <br /> SecL�dAtt� rrotL �Wc (FASO\ trite nu AS �T.LL 'IS \iAQoR Q2i,���R� gryi <br /> ZC 1�\Sv s . t \��ri fN AO. S. -o% nvwaLLtco+— <br /> T \fiIL O lL-Q, Qw 0.¢5 ( D <br /> III.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided heroin is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANKOWNEMGENT (:,on 2wc- vsw.� DATE <br /> 24Tce � CJn�M>r. JSvY�t_ Q„�y\tV�}w , 3U 'U1 <br /> NAb1E OF TANK OWNER/AGENT Qaim)CD��rt�n amok- 485. TITLE OF TANK OWNER/AGENT C ,..or+NLf4e Rup °� <br /> c-uCe\V cL? 20C--T0ti, I4s. S- 'ere'V Q-Y)W <br /> UFCF(1/99)Hwfwr -12 http://www.nnidoes.org Rev.02116/00 <br />