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a V <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (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 /> IC <br /> ADDRESS(For local use only) <br /> 476 <br /> 2-9 S GrwTAMW 1lt0(,T 6i 0 Gk'b U GA <br /> FACILITY IDEt 1 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 /> 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: lfl p C Dt,D ST_A 2t p N tIf efl F,,2_Ea r✓ <br /> MAS R -►,C11ANDC A owr <br /> 0-7 <br /> F lL(- S ttMP SZ N Sr)IJJ ct.t�l g/ 71yt26lNAi S c1M�° 5t a1sJ C. �!O Sgt,� <br /> 0PjjtA6/e-j i`1 of o- om A<c <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 ER/AGENT DATE � 484 <br /> tl Z �� <br /> NAME OF TANK OWNER/AGENT(print) '5 TITLE OF TANK OWNER/AGENT 486 <br /> RYAN M4TT14Fq -rfolmztAN <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />