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n <br />m <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Pope or <br />1. FACILITYIDEN'I'IF'ICA'I'ION <br />=311;77SINESSNAME. S-.n:�r(�ci� An�i_erDs^. D�/tl�.r 11-.i.—A4) <br />,ADDRESS (Por local usean) d7G <br />FACILITY ID# <br />TANK 1D -' 477 <br />II. INSTALLATION <br />(Check all that apply) <br />The installer has been trained and certified by the tank and piping manufacturers. 478 <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 />[�1 The installation has been inspected and approved by the Unified Program Agency. Oxo <br />All work listed on the manufacturer's installation checklist has been completed. 481 <br />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 />Loi -f .,e V -3 <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 />SIGNATURE OF TANK OWNER/AGENT <br />DATE4s4 <br />! <br />NAME F TANKOWNER/AGENT (print) 485 <br />,w -L <br />TITLE OF ANK OWNER/AGENT 485 <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />