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UNIFIED PROGRAM CONSOLIDATED FOrM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (ane page per <br />tank) <br />Page <br />_ of _ <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME a DBA — Doing Business As) <br />r <br />3 <br />a <br />ADDRESS (Fa local use a <br />. <br />476dv) <br />73 3 00`® G i q ,7 <br />FACILITY ID# <br />I <br />I TANK ID # <br />4n <br />II. INSTALLATION <br />(Check all that apply) <br />staller has been trained and certified by the tank and piping manufacturers. <br />478 <br />installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />with underground storage tank installations. <br />:� <br />The installation has been inspected and approved by the Unified Program Agency. <br />Oso <br />All listed the installation has been completed. <br />481 <br />work on manufacturer's checklist <br />42 <br />tinstaller has been certified or licensed by the Contractors' State License Board. <br />heunderground 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 />;V,eo,- V10? 4) 0 <br />o- <br />III. TANK OWNER/AGENT SIGNATURE <br />I certify that the information provided and accurate to the best of my knowledge. <br />SIGNA F <br />DATE <br />494 <br />NAM FOWNER/AGENT (print)_ <br />TITLE O TANK AGENT <br />4 s6 <br />. <br />l <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />