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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (tine Page per tank) <br /> Page of <br /> 1.FACILITY IDENTIFICATION <br /> E <br /> ES M (same as FACILITY NAME or D —Doing pusinessESS Far dotal us o� / � �/(( r ,r , �L _ 476 <br /> FACILITY IDB �j/i /�1JfJ/A,f uc9(/ilyf��—� (f j pW4r`/rj[7ANK <br /> ID k [qj \ 477 <br /> 11. INSTALLATION <br /> (Check all that apply) <br /> 478 <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 479 <br /> with underground storage tank installations. <br /> 480 <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. 482 <br /> ❑ The underground storage tank,any primary piping,and secondary containment was installed according to applicable 4ss <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified; <br /> 51. ^r P,,es,5ew sensrrR wees Ref 14 unde—e Dyekser-*g!a. <br /> III. TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAUJRE OF TANY,OWNER/AGENT DATE 484 <br /> B-3-07 <br /> NAME OF TANK OWNER/AGENT(print) 495 TITLE OF TANK OWNER/AGENT 48e <br /> 0-b r /Or-KennG <br /> UPCF(1199 revised) 14 Formerly SWRCB Form C <br />