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IRPKIFIED PROGRAM CONSOLIDATED FOW <br /> UNDERGROUND STORAGE TANKS —INSTA�[,1� " <br /> CERTIFICATE OF COMPLIANCE -t, (one page per tank) <br /> .. - Page—of— <br /> L FACILITY IDENTIFICATION ENVIRJNMEN*f w:,ALfr <br /> BUSINESS NAME(Same as FACILITY NAME or DBA–Doing Business As) 3 <br /> ARW -A' quX <br /> ADDRESS(For local use only) <br /> 476 <br /> L-$m-4 w4Y ST,fu:1'LP4 C4)r as 5- <br /> FACILITY <br /> FACILITY ID# 77-AN <br /> K ID# 477 <br /> H.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 /> 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 /> tf0;1ver-� 8 / Or"-iAr- 4--,nK -{� $-7 OCe <br /> K� e vV 1" over 3 " Amer on OP400 y 3n0-/t, Jeri <br /> New 3'/ ove✓ L4" VApor gyneron I DUaloy 30c,4-- <br /> M. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU .OF TANK OWNVRf*GENT DATE 484 <br /> \, `j�-� l Z z c /a7 <br /> NAME OF TANK OWNER/AGE (print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> t_j t-tS v 7 64 T 1(1707k'A-Zy C'rt- <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />