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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 or - <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Busincss As) <br />' 3t- <br />Cow- ST -o P 13t- <br />ADDRESS <br />ADDRESS (For tical use only) <br />476 <br />476 <br />FACILITY ID# <br />TANK ID # <br />03 <br />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 <br />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 <br />481 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />J�nc S T A. t, L A -T-10 P%( O F Aj EW S P I 1- L C 0 PLT A- r K 64L S <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 OWNE ENT ' r <br />�il� <br />DATE <br />484 <br />NAME OF TANK OWNS GENT print) 485. <br />TITLE OF TANK OWNERCAGfNT <br />486. <br />I c W ASC.. E . WA c,TO N( <br />0 A A-tl" f — <br />UPCF (1/99) Hwfwrc-c - 1/2 http://www.unidocs.org Rev. 02/16/00 <br />