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�+� iu�uu..+ ulJ. JJ LU J`FV VJ VJJ r Lr Irl rLUUC <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(Oncpaza per lank) <br />Se of� <br />I <br />FACIIJIT X' IbENTIFCA TION <br />13USI2VESS NAME (SnneaaF.ACILITYNAAL-or DBA—DoinpB.in.*A,) <br />3. <br />Fe, W t <br />ADD RESS (For lural wo ocl7) <br />L. <br />� t' Tk .."'r 476, <br />FAC LITY 1D# q Cdn��� ( `� R'�� <br />I TANK ID.4 <br />i <br />., .. <br />II 'PN �STci LL1�� ION E <br />t <br />(Check all that apply) <br />The installer has been trained and certified by the tank and piping manufacturers. 478. <br />,- The installation has been inspected and certified by a registered professional engineer having education and experience `79. <br />with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program AQQpencY• aso <br />b <br />All work listed on the manufacturer's installation checklist has been completed_ 431 <br />as , <br />The installer has been certified or licensed by the Contractors' State License Board. <br />JW The underground storage tank, any primary piping, and secondary containment was installed according to applicable °B3 <br />voluntary consensus standards and written manufacturer's installation procedures_ <br />esccription of work being certified: ? / <br />Q�pi n.� 3.a.TlvoP�. ci rt5. ���✓1.56 r—S �/ ' 7/5�,, �/�' ��i L / �/ Z — <br />�� u,�S +- F�f �3u,-h : vs Ep �Ff.�,X z" ,�e�► <br />'.:IIITANK OWNER/AGENT SIGN,ATiURE <br />I ecrti. that the infonnntion rovuled herein is true an <br />�' p d aceurale to the best of my knowledge. <br /><<- L <br />--... Un a e .BG. <br />Z rav� lJ <br />(print), / \ass. TITLE OF TANK041NMAGENT 4e6, <br />F-r-NPF/... i <br />(1/99) klwfwrc-.c - 1/2 http://"ww.unidocs,org <br />Rev. 02/16/00 <br />