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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 /> : <br /> LACIL)E' IDN GAT (Ol� <br /> BUSINESS NAME(Sav a as FACILrrY tv&VE or DBA—Dong BUM=M 3• <br /> ADDRESS(For useonty) <br /> 476. <br /> FACII TT Y iD# td <br /> TANK ID# 477. <br /> II.`INSTALLATI4]<T <br /> (Check all that apply) <br /> ) <br /> The installer has been trained and certified by the tank and piping manufacturers. 478. <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 47g <br /> with underground storage tank installations. <br /> 480. <br /> ❑ <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 4st. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> 481 <br /> The installer has been certified or licensed by the Contractors'State License Board. <br /> 21- The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483' <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> L(5� /!1,5-r/- U,,47,v,J VIM N&k,) P1P1A/� <br /> lII TANK ORzNRIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIG R�OF K OWNER/AGEN DATE 484. <br /> 07S q <br /> N ME OF T WNERIAGENT(p' t) 4A`p TITLE OF TANK/OWNER/AGENT 486•l y O ores `PA ) <br /> UPCF(1/99)Hwfwrc-c-112 httpJ/www.unidocs.org Rev.02/16/00 <br />