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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (ane Page per tank) <br /> i <br /> PRe_pf_ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAMES .a FAQUTY NAME or oaA-Ming ea.m...MI 3 <br /> O <br /> ADDRESS(Fm total e.e pelt) 476 <br /> FACILITY IDX I TANK ID X 4T) <br /> 2�-1Y11 e.l <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 472 <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 41 <br /> with underground storage tank installations. <br /> ® <br /> 40 <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> YI <br /> All work listed on the manufacturer's installation checklist has been completed <br /> 4U <br /> �{f 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 461 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> N S -$u <br /> 7 &770 ) [9-oC /� � 'TS Ari®RiPiA� <br /> III. TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE FTANKOWNERIAGENT DATE '��- 4w <br /> NAMEOF ANK OWNER/AGENTI inn 4as TITLE OF TANK OWNER/AGENT 414 <br /> eOA <br /> a H � pwa� <br /> UPCF(1.;99 revised) 14 Formerly SWRCB Form C <br />