Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page L <br />of-3,- <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sams as FACILITY NAME or DBA— Doing Business As) <br />i <br />v�tL S op + 138 <br />ADDRESS (For local use only) <br />47h <br />FACILITY ID#I. <br />TANK ID # <br />477. <br />01 <br />II. INSTALLATION <br />(Check all that apply) <br />475. <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 <br />J7� <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 <br />481 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />_TMSTALL A-Ttod OF K C QP4TA•tNEtss , <br />III. TANK OWNER/AGENT SIGNATURE <br />1 certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF TANK OWNE AGENT <br />L9 <br />DATE <br />1 /20 �0L( <br />484 <br />NAME OF TANK OWN EN print) 485. <br />TITLE OF TANK OWNE <br />486 <br />kk ICWA-E[L E. crow( <br />C 0AtT2A-cT-ofL <br />UPCF (1/99) Hwfwrc-c - 1/2 http://www.unidocs.org Rev. 02/16/00 <br />