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UNIFIED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS—INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page_of <br /> L FACILITY IDENTIFICATION <br /> s. <br /> BuswESSNAME(SarneasFACTUTYNAME"DBA-Doing&ssinessAs) �l "s e C o� <br /> `. �+ 476. <br /> ADDRESS(For local use only) 9 O r C Q Tr C- -l S 3� 6 <br /> 1 477. <br /> FACILITY ID# <br /> � TANK ID# <br /> Aoa a X388 <br /> IL INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> The installer has been trained ancertified tified by the tank and piping manufacturers. <br /> `�,,pp�� 479. <br /> FYUe installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 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 /> asz. <br /> ® The installer has been certified or licensed by the Contractors'State License Board <br /> 483. <br /> �.] The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> S rrN N' , coo <br /> �rn c�� 5paraQ ��ns . Q� �ro�all <br /> U s-edl dl 5�'e nt e c.: <br /> . r cJ rc�kcle � P c i rcmc., %A c.,-,,C\ Sec.o+\&C&C` .j hoc` <br /> c,rd <br /> c l�S0 nom' \; ,^Ls <br /> �e Q;p�. b o'r�►. p r; .�.a•�•-,� �...d s e-�o r.���`1 Q c o d�.c,!- \', r e m o +n1 �'I or) <br /> �-1na t�,ia.�e� 1 nio fNo vr.,�or- 1i nt-5rt-C1� <br /> III.TANK ONVNERIAGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> 484. <br /> S T OF TAN O AGENT DATE <br /> Q3 2 `l �p 3 <br /> 486. <br /> NFANE TANK OWNER/AGEM(print) 485. TITLE OF TANK OWNER/AGENT <br /> C `tvc { � oiv C7 /I/ cP, <br /> UPCF(1/99)ftwfwrc-c-112 <br /> http://www.unidocs.org Rev.02/16/00 <br />