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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 FAcn-rrY NAME or DBA—Doing Business As) 3, <br /> Waterloo Shell <br /> ADDRESS(For local use only) 476. <br /> FACILITY IDI 1 TANK ID# 477_ <br /> O1 <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 /> ® 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 481 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> Installation of a complete new UST system,including tanks,piping and dispensers. <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 /> SIGNATU OF K O E A T DATE asa <br /> Y 0 S-- <br /> NAME40F TANK OWNER/AG (print) 485. TITLE OF TANK OWNER/AGENT 486 <br /> Michael E.Walton Contractor <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />