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I <br />LDI <br />ECE�U® /914 <br />IPDEC 2 1 2007 <br />CAttimmix 4r6rr i tr"Ai "rt i <br />PERMIT/SERVICES <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tack} <br />Page _ of� <br />L FACILIW IDENTIFICATION <br />(Same as FA NAMFarDBA�-Doing BusinessAs) 3• <br />pop <br />[:DVSS <br />or 1=1 476. <br />FA�C,I,LYi/j <br />i <br />TANK ID # 477. <br />IL INSTALLATION <br />(Check all that apply) <br />478. <br />e 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 />th underground storage tank installations. <br />480. <br />The installation has been inspected and approved by the Unified Program Agency. <br />48[. <br />�,/ <br />All work listed on the manufacturer's installation checklist has been completed. <br />4U. <br />installer has been certified or licensed by the Contractors' State License Board. <br />PXThe <br />The underground storage tank, any primary piping, and secondary containment was installed according to applicable 4M. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Diption of work being certified: <br />C/1 U,�J7&j all <br />il"` <br />III. TANK OWNERAAGENT SIGNATURE <br />I certify that the inforrnation provided herein is true and accurate to the best of n y knowledge. A <br />SIGNATURE OF TANK OWNt$R/ -= ' <br />DATE / - <br />7 <br />N OFTANKOWNER/AGENT 485, <br />TITLE OF TANK OWNER/AGENT 486• <br />M -CF (1/") Hwfwre-c - I/2 http://www.nnidoes.org <br />I- d abE9 i 9ir60Z ou I 5J010e.aqu00 AI e4 t i 3 <br />�v �ev. 02/16/00 <br />ebb:60 LO 12 09a <br />