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a <br />Ah <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA —Doing Business As) 1S / / <br />rtTPWcc Fae 1 (o OC7 <br />3. <br />ADDRESS (For local use only) V476. <br />/I a'7 r/� 95-376, <br />FACILITY ID# <br />I. <br />I TANK ID # <br />477. <br />H. INSTALLATION <br />(Check all that apply) <br />E The installer has been trained and certified by the tank and piping manufacturers. <br />478, <br />E__ -The installation has been inspected and certified by a registered professional engineer having education and experience <br />479_ <br />with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />aso <br />All work listed on the manufacturer's installation checklist has been completed. <br />481. <br />The installer has been certified or licensed by the Contractors' State License Board. <br />482. <br />[Lj'*'_The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />481 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <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 OWNER/AGENT <br />DATE <br />484. <br />NAME OF TANK OWNER/AGENT (print) 485. <br />TITLE OF TANK OWNER/AGENT <br />486 . <br />f <br />�J <br />-7 ,5/16 //P, <br />UPCF (1/99) Hwfwrc-c -1/2 http://www.unidocs.org Rev. 02/16/00 <br />