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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> /� <br /> BUSINESS NAME(Same as FACII.TTY NAME or DBA— � Business As) 3 <br /> �1/� � <br /> �S�� , <br /> ADDRESS(For local use only) <br /> 476 <br /> q c C <br /> FACILITY ID# tANK ID# �_ �(� 471 <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 /> El 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 /> T— All work listed on the manufacturer's installation checklist has been completed. <br /> asz <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 /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN O ANK _R/AGENT C)J DATE a� 484 <br /> C� <br /> NAME OF TATJK OWNER/AGENT(print) 485 TITLE OF TANK OWNER/AGE 486 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />