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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Papa _ of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME S.sa FACILrIY NAME ar DBA-Dung Boma As) 3 <br /> S v C%!: <br /> ADORESS(ForM Meery/ 476 <br /> rnlrJ qoLT v S c� <br /> FACILITYIDa I i) t TANKIDO All <br /> I I <br /> t ' <br /> II. INSTALLATION <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. Ava <br /> i <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. .eo <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. u, <br /> The installer has been certified or licensed by the Contractors' State License Board. .az <br /> ❑ The underground storage tank, any primary piping, and secondary containment was installed according to — <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> NOW PRQDuCT APO \APOk ReCovMy PIP(NCT/ NP-W R(WOTg <br /> ThWK FILLS AW Wok RrscoVM\f Rlsei,S, QL51LOCAT OtJ OF j <br /> "7� f� CtAS�Cl�� bIS��NS��S, RUFcoNNeCT(on! of VA21OUf <br /> P20stT AW OTH-Iza 1\4 P 01? MoO I RI CAT 10All. <br /> III. TANK O NER/AGENT SIGNATURE <br /> I curry Ina Ire nlorm rovKlaO reran n Vue accu.a o VM Daft of my snow s <br /> SIGNATURE OF T OWNER/AGENT DATE qq A saA <br /> 1� <br /> NAME OF TANK OMd1ERIAGENT(MN) 485 1 TITLE OF TANK OMMER/AGENT "aa <br /> ( rZN t , tvro CoN srnuc-no I MAAe- PAL I <br /> ENin2P21scu b, c <br /> UPCF(1/99 revised) 8 Fonnerty SVJRCB Fonn C <br />