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MAY 20 2000 2: 31PM HP LASERJET 3200 p. 4 <br /> UNIFIED iROGRA#4 C�OvNSOLMA'TED FORM <br /> STORAGE <br /> UNDERGROUNDSTO E TAN —INSTALLATION <br /> CBRTIFICAVE OF COMPLIANCR <br /> (One pegs per umk) <br /> Par=: <br /> 1.FACILITY 109MMICATION' <br /> BUSINS33NAME i34m4mFACILUTNAMA*rOBA-04imsBakma s) '• <br /> ADDRESS p«6w w.4y) . <br /> P <br /> V � <br /> FACtLrff IDN •.":� <br /> U.11!4# 'nOW <br /> (Ch .tt thea op0y) <br /> ns <br /> ❑ The installer has been trained and certified by the tank andipiping manufaaturm. <br /> ❑ The installation has been inspected and mdfiod by a reolsterad profoulonal engineer having education and experience "'' <br /> Zile <br /> underground storagetank installations. <br /> installation has been inspected and approved by the Uoifioi ProSm Agency. .Da <br /> Ala work listed on the manufactumes installation checklistiW been completed. 401. <br /> installer has lint'certified or.lieensed by the Contraetos'State Licence Board. <br /> ❑ The uthdoMmund storage.mk, any primary piping, andi"adary containment was installed according to applicable a". <br /> voluntary cots tsus standards and written manufacturer's jintallation prooedures. <br /> Description of work being certified: <br /> Illi•TANK O . . wT SLGNA <br /> t s ify that clic tTsados provided ha ein is hum and arwat.to tht bat orm ikWwisdae. <br /> S DATt3 J 4te. <br /> x oP r °e U ofeuni<o �a . <br /> UPCF(IM)Hwfwrc-c-1R httptliwww.o$kdoc'.oR Roy.62116/00 <br /> E'd 5b>=t3t}9b:01 :W08A d9S:20 L202-22-AUW <br />