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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE one paga Kr tank) <br /> Pag _of_ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Syne u FACILITY NAME.,DBA-Doing Bwmev A4) 5 <br /> ADDRESS(For lain..Wy) 476 <br /> FACILITY IDN I TANK ID N an <br /> cpreseo <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ng <br /> fig. 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 /> ago <br /> f 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 /> au <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 40 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III. TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN UREOFTANKOWNER/AGENT DATE 454 <br /> NAME OF TANK OWNER/ GENT riot) a85 TITLE OF TANK OWNER/AGENT 488 <br /> aK o 0 A/Q2 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />