Laserfiche WebLink
4� 4 <br /> D PROGRAM CONSOLIDATED FOO Q,// <br /> TANKS l4r% <br /> UNDERGROUND STORAGE TANKS— INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page pe'[lank) <br /> Page_of <br /> L FACILITY IDENTIFICATION <br /> 3 <br /> ME . <br /> BUSINESS NA (Same as FACBd7Y NAME or DBA—Doing Business As) Q C J <br /> 476. <br /> ADDRESS(For local use only) TC C � <br /> S O �— 5'�t c e l 4n. <br /> FACILITY IDN l TANK ID# <br /> FA00063Le <br /> II.INSTALLATION <br /> (Check all that apply) <br /> I 478. <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> a79. <br /> 0(\ e installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 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 /> ase <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 /> ea nq-�-JJ, A .0 ���� <br /> �- Q �G s . Q e'rod <br /> �» <br /> nY.S �0 1Ret,�3 C�� 5pe,ns <br /> P P 5 5 <br /> r\ <br /> fep;p,� bo�M. Prinr+e.�� <br /> vn <br /> e. v%A 5e -1l <br /> o v a o c- l i lrn 4e, <br /> %u <br /> IM TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> 4a4. <br /> SI A OFT KO AGENT DATE <br /> a3 -z � - c� 3 <br /> 4ss. <br /> NAME OF TANK OWNER/AGENT(print) �5. TITLE OF TANK OWNER/AGENT <br /> fCA- C r�'2 <br /> UPCF(I/99)Hwfwrct-1/2 �� <br /> h //www.anidocs org Rev.02/16/00 <br />