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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> L FACILITY IDENTIFICATION D1 ��� l ,� -n ID) <br /> BIIISINESS NAME -as FACILITY NAME or DIA—Doing Business As) 3 <br /> (�6-t afcft(ke fooD 4 <br /> ADDRESS(F&local use only) 476 <br /> HEALTH <br /> FACILITY ID# TANK ID# -t I-�) (�[�' <br /> 1 PF—R Iff/S �.El`,�(GLS477 <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 /> Oso <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 /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that n <br /> nfotmati rod erein' ccura a to a of my knowledge. <br /> SIGNATU F DATE 484 <br /> NAME OF ANKER/ NT(print) 485 TITLE OF TAN OWNER/AGENT 486 <br /> '02.17 C I C1 P. <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />