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UNIFIED PROGRAM CONSOLIDATED FORM <br /> D, ,TANKS <br /> UNDERGROUND STORAGE TANKS- INSTALLATION <br /> CERTIFICATE OF COMPLIANCE ENViiq L-; (one page per tank) <br /> Page of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> A 2—co .� SZ(09 S" <br /> ADDRESS(For local use only) 1 ``OCIL 476 <br /> 30 o <br /> 5 , w , lsn WAy S-F -�-or Zfl <br /> C� `l'� s <br /> FACILITY IDI I I TANK ID# 477 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479 <br /> with underground storage tank installations. <br /> 480 <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> 482 <br /> Q'The installer has been certified or licensed by the Contractors' State License Board. <br /> The underground storage tank,any primary piping,and secondary containment was installed according to applicable 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> $7 06 -G-- n k <br /> Neuf ove✓ 3i/e•�-� <br /> /vif °'� .3 " dve Y 6`ii (1.4�dr l� ' }�L' l4.,"e✓6,ri 3oc�o /L <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 OWNER/AGF14T DATE 484 <br /> NAME OF TA K OWNER/AGENT(pn t) 485 TITLE OF TANK OWNER/AGENT 486 <br /> Wt !6j ryl/ka,rx ZY-- <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />