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ft <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Faye L 01 .1 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sm ea FACRITI'NAMEar DBA -Doing Business As) <br />ELLt1 w F2c 1GN i <br />3 <br />ADDRESS (For iod,.e omy) <br />/� 375 5-frre,4D&2a IN6 <br />ors <br />FACILITY ID# <br />I I I TANK ID # .^ aS T -E oil, <br />4n <br />H. INSTALLATION <br />(Check all that apply) <br />❑ The installer has been trained and certified by the tank and piping manufacturers. <br />era <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />4 s <br />with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />4110❑ <br />All work listed on the manufacturer's installation checklist has been completed. <br />481 <br />installer has been certified or licensed by the Contractors' State License Board. <br />4VThe <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />483 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />INSTA«ATiow b)c' #303 VL=EoEla Reo� <br />S� A(S0/2 - f4XlVaJ-AYZ <br />___ ---------__. --_-III:_TANK-OWNER/AGENT SIGNATURE -.- <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF TANK O WNER/AGENT V, <br />DATE <br />484 <br />NAME OF TANK OWNER/AGENT t 4ss <br />J,IIJJ 30wL <br />TITLE OF TANK OWNER/AGENT <br />C014Pj1.41VC6 /}NAGEi2 <br />46 <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />