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Jan 10 03 04: 33p Vie Brown (200 461-6342 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED(FORM C <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (OQC pagC per Gt6tC) <br /> Pil&C�Of <br /> L FACILITY IDENTIFICATION <br /> 3. <br /> BUSINESS NAME(Same u FAC1UTYN N1E or DRA-Doing&j:s ft=As) T e,VY, o <br /> M. <br /> ADDRESS(I`ar1nra1--ly) 1?1L <br /> ate. <br /> FACiLrry ID# t. TANK ID it <br /> 1L INSTALLATION <br /> ' (Check ail4hat apply) <br /> aux. f <br /> The instatIer has been trained and certified by the tank and piping manufacturers <br /> &Ai <br /> �qq <br /> Iinstallation has been inspected and certified by a registered professional erigintxs having education and experience 4". <br /> with underground storage tank installations. aro. <br /> The installation has been inspected and approved by the Unified.Program Agency. <br /> art. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> aea. <br /> The installer has been certified or licensed by the Contractors'State License Board. <br /> ass. <br /> The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> aC-),S nt1Gt) Nc L.A) 19. 0 , Sm ' -FW 0v �31e 1,.)A L L 1= %Rrti G191:35S <br /> Ex,`s 1 — (, TQ.-,tLS Tp AJ E4--> Z) "'s t2r,seA- -,s <br /> L4-S C- 0 !' S n�CYYS eQ_5 <br /> .f w5_. <br /> L1SC-Cu �la2 l=vR �'N`� <br /> 1-70T1, l2.ea.-,X ,Qr,C) SC--CcY4217'20r- Leve <br /> c) TN4. + £S-e- LL ,'ntS 9 <br /> �I V l/'ba ti t: tZ r2. C--C;z <br /> III.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowled6e. <br /> 184, <br /> SIGNATURE OF TANK O ^ DATE <br /> 10 — o3 <br /> AA <br /> NAME OF TANK OW R/AGbWr(pri a85. TrrLF OF TANK/Or WNERlAUEN <br /> �7ht(PW .unkUWs.oag Rev.02116!00 <br /> UfCrr(1/94)Hwrwrc-c-112 <br />