Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page pertank) <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) <br />3 <br />Al <br />ADDRESS (For local use only) <br />476 <br />3 3 w'+ 5 -7 -Ce '7-c? ltl e;19 <br />FACILITY ID# <br />l <br />TANK ID # <br />477 <br />II. INSTALLATION <br />(Check all that apply) <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 />480 <br />The installation has been inspected and approved by the Unified Program Agency. <br />l� All work listed on the manufacturer's installation checklist has been completed. <br />481 <br />The installer has been <br />482 <br />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 />voluntary consensus standards and,written manufacturer's installation <br />483 <br />procedures. <br />Description of work being certified: <br />III. TANK OWNER/AGENT SIGNATURE <br />I cert* tion provided herein is true and accurate to the best of my knowledge. <br />SIGN OFTDATE <br />484 <br />AME OF TANK O nt) '� <br />TITLE OF TANK OWNERIAGENT <br />486 <br />4 �G — <br />e- N <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />