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Apr 15 0& 11:16a Sandra Barnhart 2098458586 p.2 <br /> U71F"MEO PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATR OY COMYLL4lvC E We PW r-—t) <br /> L FACILITY IDENTIFICATION <br /> SU41NE9S NAME ts.mem FAC UMVWAW'r WDBA-Doig A* } <br /> _ n <br /> ADDRESS�.c�5'�� <br /> FACiLTTY tDtl <br /> 1 '[TAVKIDJ <br /> Q.INS TAL.LA'110N <br /> (Chetkail A&apply) <br /> m <br /> Q The installer has been trained andeatified by the tank and piping mafarf ctwers. <br /> ❑ The installation bas been inspecMd and certified by a registered prinkssional engineer having edu:ation and experience <br /> with undcrgmund storage tank installations. <br /> 480 <br /> The insmUstion has beer►inspeetad and approved by the Unified Program Agen�y- <br /> !$[ A3 a-ork listed art the rmrw&Cl urer's insUlatinrt checklist has been aompleood <br /> az <br /> The installer has been certific d ar h==ued by the Contracove State Liocnvc Board. <br /> Q The underground storage tank AnY PimarY PipinP,and secoodary wrrtainmentwas instilled atmording to applicable "' <br /> voluntary consensus standards and written manufasmrer's into won procedures. <br /> Desmptiotr of work being certified: c I/I _ ft <br /> u C e�e.f (r, 0. lYi.uL+e <br /> �o -Tr: ti a.Tan <br /> ( 40 l xx— 4,qd ro S ja�C Lr a_k,. ��S{" t.�i�-��. �v►;���o� i�1 t C��e <br /> 4c..,z r �re) SSC L ttl -1,,3,r `�/uz o"i(ws; a rid arrrcvat <br /> AI. TANK OWNER/AGENT S)GKATURE <br /> certify tW the inContrsatioa M nded herein is trot and acwnte to the best ortsty knowledge. <br /> 4tGNATURE OF TAX C/} NEVAGENT DATE � <br /> lJ <br /> NA-ME-OF t1F TAri1C G NI7tfAG .1print) `as TITLE OF TANK OWN A-UAGEW �s <br /> U?CF(1199Tevi5ad) 14 Formerly SWRCB Form C <br />