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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (DM page per far*) <br /> Pelta _ of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same u FACILITY NAME or DBA-Darp 9uaneaa Ae) B <br /> I Cilia O <br /> ADDRESS liw4ral us a- <br /> 476301 Ol'f S F I <br /> FACILITY ID• : p I I t TANK ID• _ 477 <br /> f I <br /> II. INSTALLATION <br /> (Check all that apply) 1 <br /> The installer has been trained and certified by the tank and piping manufacturers. 4711 <br /> ' ❑ The installation has been inspected and certified by a registered professional engineer having education and 479 <br /> experience with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. 4110 <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. 401 <br /> X The installer has been certified or licensed by the Contractors' State License Board. 4117 <br /> ❑ The underground storage tank, any primary piping, and secondary containment was installed according to 4" <br /> applicable voluntary consensus standards and written manufacturers installation procedures. <br /> Description of work being certified: <br /> KtauJ Pac0LX7 AND V"09, R�calea2y P I P I NF R�Nt i <br /> -FPfJK RuS Aw Uftpo2 (L�eCOVr✓7zy RISe7Rs ReI.001) OF <br /> -Pile cA&WKIe, DfSpe►JSMS/ RU5CONNIOCT J CF VA2IOUT <br /> PRODS, AnIP QIl- M MIrJop Moo IF1CA7ONS . <br /> Ill.TAN WNERIA NT SIGNATURE <br /> ,canny,na,me mldmalUn pmvKME nerd IrNa 4nd accurma Ip IfM ,01 m bOge <br /> SIGNATURE OF TANK OVVTIERIA T DATE 4114 <br /> 13/ <br /> 3 99 <br /> NAME OF TANK OweER/A ENT(peM) 405 I TITLE OF TANK OwNE AGENT 411a <br /> t N <br /> V�Fv, - <br /> UPCF(1/99 revised) 8 ��f Jn C J LLC Fortnerty SWRCB Forrn C <br />