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0 0 <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 /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> A. Teichert & Son, Inc. <br /> ADDRESS(For local use only) 120 Frank West Circle 476. <br /> FACILITY ID# I. TANK ID# 477. <br /> JF�Aj 0 121110 �7 � 39-00051536505150368 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> ® The installer has been trained and certified by the tank and piping manufacturers. <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 /> 480. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 481. <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> 482. <br /> ® The installer has been certified or licensed by the Contractors' State License Board. <br /> Pq 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 /> Remove 211 gravity line from lube pit to waste oil tank. <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 OF TANK OWNER/AGENT DATE 6-14-07 484. <br /> NAME OF TANK OWNER/AGENT(print) 485, TITLE OF TANK OWNER/AGENT 486. <br /> George Takemori Division Administrator <br /> UPCF(1/99)Hwfwrc-c-1/2 www.unidocs.org Rev.02/16/00 <br />