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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 /> BlJ$DnfE$$NAME(Smveaz FACnIr1 NAMEaDBA-DomB auveen As) <br /> -476 <br /> ADDRESS k'oriaat <br /> FACILITY IDN TANK IDN an. <br /> IL INSTALLATION <br /> (Check all that apply) <br /> ne. <br /> The installer has been trained and certified by the tonic and piping manufacturers.❑'N�he�ntstallation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. <br /> aeo. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> tet. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> rsz. <br /> ® The 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 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> pS:r\sx4k fie \ �,, )A . o Srv.,�l� �or..R�� WAv` �� • P� G�wSS <br /> c'20� <br /> `Y 1ST LC O .s�ennLe �LS. <�:5 �j • , �L ',(fie\1nc�es er�b3� cT Q Lirr`AVA A.1� <br /> Se.C.e HV-• �n�sL `Cv�t GASC`.rvv.t As VAOL Qt2.:•+y.AR1) Art <br /> ZN ALSv , L\�a*i <br /> \A -e_ Q Rio a-�.e� L,\ l.zS �tt O: •z52J� . � .ti5 e.l. (L-Z R..N\24> rti b <br /> ?+47 In TANK OWNERIAGENT SIGNATURE <br /> I certify that the infortuation provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OFh TANKOWNERLAGENT (:,Dn-Yt=ac. Vater DATE aea. <br /> �4s-C. C..O•.-NR.AC"e osU, -=r..L Pa•�W W F�paA.,.� - 3 U .(� 1 <br /> NAbfE OF TANK OWNER/AGENT(print) as TITLE OF TANK OWNER/AGENT 0nILACAV, aea. <br /> [-\2%NL W C0-4CLIsc_C'uCNL� 1.4-v, ES .cVgvz tour <br /> UFCF(1/99)Hwfwrct-1/2 http://www.unido org Rrr.02/16100 <br />