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9 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of_ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS N ME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> ADDRESS(For local use only) 476 <br /> FACILITY ID# I TANK ID# an <br /> TI I I I I I I I I I I I I <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 /> Q--l'The installer has been certified or licensed by the Contractors' State License Board. 482 <br /> ❑ The underground storage tank,any primary piping,and secondary containment was installed according to applicable 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 /> SIGNATURE TANK OW AGENT DATE p� 484 <br /> �J c� <br /> NAME OF TAN (pri aas TITLE OF TA14K OWNER/AGENT �6 <br /> e <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />