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1 —1. iv: cu rkkA LVygoo]43.5 JJt; EMU 0002003 <br /> SCJ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page—of� <br /> I.FACILITY IDENTIFICATION <br /> BUST ESS NAME(Samea�FACn.)TYNAME orDDA--DoingBusiness As) 3 <br /> 22r/r/c <br /> ADDRESS(rot local use only) 476 <br /> I/ Alk. <br /> FACILITY tD# l TANK ID# 4�. <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ❑ The installer has been trained and certified by the tank and piping manufacturers. 478_ <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479• <br /> with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. 480. <br /> All work listed on the manufacturer's installation checklist has been completed. 481. <br /> The installer has been certified or licensed by the Contractors'State License Board. ase. <br /> ❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable 183• <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNERIAGENT SIGNATURE <br /> 1 cortify that the information provided herein is true and accurate to the best of my knowledge. <br /> [;SIGN�PRE OF K 2GENT(print)ENT DATE 484. <br /> ANK O N 485• OF TRNK OWNER/AGENT 486. <br /> UPCF(1/99)Hwfwrc-c-1/2 mmunidoes.org Rev.02/16/00 <br />