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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 /> 01IL Stun + 39 <br /> ADDRESS(For local use only) 476. <br /> Z zkS' ST. S-roGrp -r-o� C 9 SZo .5 <br /> FACILITY 1134 I TANK ID# 477. <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 471 <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 /> The underground storage tank, any primary piping, and secondary containment was installed according to applicable 481. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> f <br /> 9% T-A.LL 41-to�A 0F. Kr1w L) d C C _ <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 OY#ERUAGENT DATE 484. <br /> NAME OF TANK O /AGENT(print) 485. TITLE OF TANK OWNER/AGENT 486. <br /> YM ( C 9 A-f-t- A C O►4 pr—". WA LT0,4 Fit K 14 tz r 14 <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br /> 0 0 <br />