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UNDERGROUND STORAGE TANKS - INSTALLAT10i <br />CERTIFICATE ,; COMPLIANCE <br />(one page per tank) <br />L FACILITY IDENTIFICATION <br />s� <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) <br />3 <br />ADDRESS'S (For local use onk) <br />kco <br />476 <br />FACILITY IDI# <br />t <br />TANK ID 9 <br />477 <br />II. INSTALLATION <br />y (Check all that apply) <br />l> t <br />The installer has been trained and certified by the tank and piping manufacturers. <br />478 <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />with underground storage tank installations. <br />Q ° . The installation has been inspected and approved by the Unified Program Agency. <br />480 <br />i All work listed on the manufacturer's installation checklist has been completed. <br />481 <br />The installer has been certified or licensed by the Contractors' State License Board. <br />4V <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />483 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />/ t <br />A S4 e (I <br />t <br />r <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 />SSG A RE OFT I WNERJAGENV <br />U -CAICI <br />DATE494 <br />1 1 , <br />///ZD Zoof <br />NA E OF TANK OWNER/AGENT (print) 4xs <br />TITLE PF TANK OWNER/AGENT <br />486 <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />