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9 <br />e <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Page <br />of _ <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business As) <br />3 <br />D 'I j2,v V <br />DDRESfS(For iocaluse only)e <br />476 <br />FACILITY ID# <br />TANK ID # <br />477 <br />II. INSTALLATION <br />(Check all that apply) <br />�The <br />478 <br />,21 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 <br />47' <br />with underground storage tank installations. <br />480 <br />2/1"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 />ff <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 <br />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 that the information provided herein is true and accurate to the best of my knowledge. <br />S G,, URE OF T WNER/AGEN <br />DATE <br />484 <br />►. <br />lAti <br />i 1 2d <br />NA%E OF TANK OWNER/AGPNT (print) 485 <br />4iA-f-u)is <br />TITLE Q TANK OWNER/AGENT <br />486 <br />i1 <br />pw ce <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />