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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 T <br />of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACH TY NAME or DBA — Doi g Business As) <br />3. <br />ADDRESS (For tical use only) <br />476. <br />FACILITY ID# <br />1. <br />TANK IDAI <br />477. <br />II. INSTALLATION <br />(Check all that apply) <br />The installer has been trained and certified by the tank and piping manufacturers. <br />478. <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />with underground storage tank installations. <br />480. <br />IB/The installation has been inspected and approved by the Unified Program Agency. <br />All work listed on the manufacturer's installation has been <br />asl. <br />checklist 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 />483. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />Ail -),0P c lc <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 OWN R/AG N <br />ow <br />DATE <br />484, <br />NAME OF TANK OWNER/AGENT (print) 485. <br />TITLE OF TANK OWNER/AGENT ® <br />486. <br />($ <br />UPCF (1/99) Hwfwrc-c - 1/2 www.unidocs.org Rev. 02/16/00 <br />