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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS —INSTALLATIO►N <br /> CERTIFICATE OF COMPLIANCE <br /> (one Page Per tank) <br /> 1-.ge�of <br /> -7 <br /> L FACILITY IDENTIFICATION <br /> 3. <br /> BSJStt�IESS NAME(samcas>=nc�-rvxnt��Ran—Roing����,+�) <br /> L NN 476_ <br /> Al7DRES S ff=1m l us';msy) <br /> uv w . c�a�r -- ` 3 b 4n <br /> PACI1..r1 Y ip# TANK lA N <br /> IL INSTALLATION <br /> P <br /> (Check 0 that apply) <br /> I <br /> 478- <br /> T/he installer has been trained and certified by the tank and piping manufacturers. <br /> stallation has been inspected and certified by a registered professional engineer having education and experience 479. <br /> with underground storage tank installations. 4& <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 4s1 <br /> �j All work listed on the manufacturer's installation checklist has been completed. <br /> 4$2. <br /> The installer has been certified or licensed by the Contractors'State License Board. <br /> rimpiping, and secondary containment was installed according to applicable 00The underground storage tank, any P �'' <br /> voluntary conscrtstts standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> 1 <br /> �.�•`��� �� rR.��,�,.ti �.x �S�-�r,�. �;, A�n.k.5 "'C � ��-'�-u �j',S��--��:� ��'�ri,,� s �,e_:��v s�.�L�.. <br /> Se v.,d 8-q-n — , '�a t G ,5 5 cL t n L r\-c--, �S <br /> ���UITA�NKOVW�FNIER/AGENT SIGNA'T'URE <br /> I certify that the information Provided herein is true and accurate to the best of my Lnowledge. <br /> DAT£ eras. <br /> SIGNATURE OF TANK 09VNIJR�AGENT <br /> AC v� F I�V <br /> y> z C.vrr��.r>c C,;:y4 <br /> 4ss. TITLE OF TANK OWNERIAGENT 466 <br /> NAM£OF TANK OWNERJAt'ENT(print)t--L),-1 VLrA L <br /> L W C-o"'T 2 rC.-T ca tN-� $s,k-,"�-1 4 <br /> UPCF(1199)Hwfwrc-c-112 http:l/www.anidooLorg Rev.02116/00 <br />