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Ask <br /> UNiF1ED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> :UXDE:RGRO'LNTD STORAGE TALI KS- LNiSTALLATION <br /> CERTTFICATE OF C011iPLIAhCE <br /> (Onc page per tank) <br /> Psge`of� { <br /> i <br /> I.FACII.ITY IDENTIFICATION <br /> BUSINESS NAME(smm u FACUM NAS E,x DBA-Doft B=i"m.,+) ` <br /> ADDRESS(For tocat uo ontr) +76. <br /> FACILITY IDH t TANK IDH 477. <br /> i <br /> U.INSTALLATION <br /> (Check all that apply) <br /> li <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 A79 <br /> with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. 482. <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 /> I <br /> I, <br /> I <br /> III.TANK OWNEWAGENT SIGNATURE <br /> I certify that e' orrnation provided hmin is true and accurate to the best of my kno%-ledge. I <br /> SIG OF R! GENT DATE 484. <br /> 7 �,�n �C7 <br /> OF TANK O GEN t) ,� WC-C4,9!- TITLF.OF TANK ONVIN"E fAG 46. <br /> UPCF(1199)Hwfwm-c-1/2 http /lwaT.urtidocs org Rev.02/16/00 <br />