Laserfiche WebLink
0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGRO STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Page _ of _ <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) <br />3 <br />ADDREStS (For 66 we onk) ; <br />Ko e) <br />476 <br />FACILITY ID# <br />1 <br />TANK ID # <br />477 <br />II. INSTALLATION <br />! (Check all that apply) <br />I s <br />2-1 <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 />A79 <br />with underground storage tank installations. <br />TThe <br />installation has been inspected and approved by the Unified Program Agency. <br />480 <br />All work listed on the manufacturer's installation checklist has been completed. <br />481 <br />yThe installer has been certified or licensed by the Contractors' State License Board. <br />48< <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />°1833 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />t <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 />OF T N{� <br />Sfc%WE J�ti <br />DATE - <br />ast <br />tf -2 <br />2 <br />NA ji E OF TANK OWNER/AGENT (print) 49S <br />TITLETANK OWNER/AGENT <br />4s6 <br />