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UINIFI U rMUUKArd CONSULIVATED FORM <br /> TAU <br /> C <br /> UNDETAOUND ST TANKS <br /> NSCLAyON <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of_ <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(SameasFACILMYNAME orDBA—Doing Businew As) 7 <br /> ADDRESS(Fm meal use only) 476 <br /> —717 w. 9? 4e5- T E-7- ?®d G.X T®1v <br /> FACILITY ID# t TANK ID# 477 <br /> �t <br /> ®o® <br /> 4-AL A/�E s �-- n-` G-v -z o® v 5e*AL <br /> II.INSTALLATION <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. 47$ <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience d9 <br /> with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. �s <br /> [' All work listed on the manufacturer's.installation checklist has been completed. est <br /> 482 <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> e 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 /> IIi. TANK OWNER/AGENTSIGNATURE <br /> I certify that thin <br /> formation provicr herein is true and accurate to the best of my knowledge. <br /> SIGPIAT "FAN O DATE Z484 <br /> a <br /> NAME OF TANK O AGENT(print) ass TITLE OF TANK WNER/A ENT 496/ <br /> UPCF(I revised) 14 Formerly SWRCB Form C <br />