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URFIED PROGRAM CONSOLIDATED FO <br /> I �°3 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (One page Per tank) <br /> Page_of_ <br /> L FACILITY IDENTIFICATION <br /> 3. <br /> BUSINESS NAME(Sano as FACB37Y NAME or DBA-Doing Business As) 1 n C J <br /> c 476. <br /> ADDRESS(For local use only) Q 1 5 r c e _TCG S' v 3 6 <br /> 1 477. <br /> LTANK ID# <br /> FACILITY ID# <br /> 0 0 6 6 36 <br /> 8 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> Ij The installer has been trained and certified by the tank and piping manufacturers. 479 <br /> [fi\)Pe 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. 48t <br /> All work listed on the manufacturer's installation checklist has been completed. 482 <br /> ® The installer has been certified or licensed by the Contractors'State License Board. <br /> 40. <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 /> �� 1 <br /> pip:�5 �ro�rn CX� 51-i n� -an1F.5 �o nes, 3 C\ <br /> ,,e �ans . �e <br /> C <br /> ire\ke\e P� i Mc.r ,,e�\ SeC-o�e�•�r` <br /> r `1 <br /> dor �.� Ue.por <br /> \,r�S dna Pfirr-)o.r� C,,\A se C_0V., (XC.11 <br /> For �c,so�: .n�. or\\-I ) 1 on <br /> �o�a��•1 p �oautLf �'� re. <br /> �'�Q- diene\ 1 rim fNo v& Pur- 1in4t5 CC Al <br /> III.TANK OWNERIAGENT SIGNATURE t <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> 084. <br /> SI AT OFT R/AG DATE <br /> 486. <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWN E AGENT <br /> C A r,,_ c k Dow c�t � <br /> Rev.02/16/00 <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.usidocs.org �` <br />