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0 • <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE 2005 page per tank) <br /> Page_of <br /> I.FACILITY IDlr <br /> IDENTIFICATION SAf `j�k i �T ii id T Y <br /> tdYllROP,Mi_r�ETAL <br /> BUSINESS NAME(same as FACILN7 NAME or DBA—Doing Business As) HLN 3 <br /> rN C <br /> ADDRESS(For local use only) /. 476 <br /> FACILITY ID# l TANKb# � (]r 4,n <br /> H.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> The 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 /> with underground storage tank installations. <br /> 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 /> 482 <br /> The installer has been certified or licensed by the Contractors' State License Board. <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 /> �. <br /> M. TANK OWNER/AGENT SIGNATURE <br /> I certify thf the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA OF OArGENT DATE 484 <br /> (� © - <br /> NAME TA OWNER/AGENT(print) 485 TITLE OF TANK WNER/AGENT 486 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />