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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one pageper tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS N ME(Sam as FACILITY NAME or DBA—Doing Business As) 3 <br /> 76 <br /> ADDRESS(For local use only) 476 <br /> 4 <br /> FACILITY ID# I TANK ID 477 <br /> .466W, : <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 /> The installation has been inspected and approved by the Unified Program Agency. ago <br /> 481 <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> 91*10'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 /> loLr-.ea &- S �t V�J 'S1e..�k l'Srs <br /> 41 54-b' .A'S <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 /> SIGN EOF WNER/AGENT DATE as4 <br /> 5— <br /> NOF R/A ENT(print) 485 TITLE OF TANK OWNER/AGENT ® e 486 <br /> 'F a <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />