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0 • <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS — INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (onepagepertai) <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME IS.n FACILITY NAME w DBA-Doing Ammer M1 I <br /> ADDRESS(Fwmml.r y) 476 <br /> 18- 54 EAs r rhe ZOO -Z a? ` LVAs.M.t) <br /> FACILITY IDp 1 TANK ID k 4n <br /> 1 N <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ® <br /> an <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 4n <br /> with underground storage tank installations. <br /> 4110The installation has been inspected and approved by the Unified Program Agency. <br /> ul <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> eu <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 467 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> IN�r-a-u-q�no..� e� New US-+-'s qNp ptp�Ns <br /> 1II. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU OF TANK OWNERIAGENT DATE 481 <br /> -�oa <br /> NAMED ANKOWNER/A�'4ENT pnnq J85 TITLE OF TANK OWNERIAGENT 4" <br /> laal .V-0- <br /> UPCF(U99 revised) 14 Formerly SWRCB Form C <br />