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UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS— INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (orc pig per tank) <br /> Page_of <br /> 1.FACILITY IDENTIFICATION <br /> } <br /> BUSINESS NAME(same as FACU-nY NAME«DHA-Ming INSSineaa as) <br /> 5 H F LA— 476 <br /> ADU may$(For lomat uw only) 5; T I2-f- T S T O <br /> CA- <br /> FACILITY ID# 7 [D# <br /> a3� p p <br /> 2® ®® v (rA.(„ SVP 2 tn'1�- ! D 1 1,s.I; t_ Poo <br /> II.INSTALLATION° <br /> (Check all that apply) <br /> 472 <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> 479 <br /> ® The installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. ,W <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 bee n completed. <br /> ag„ <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 /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III. TANK OWNS AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN F TANK O R/AGENT DATE 44 <br /> TITLE OF TA owN R/AGENT esb <br /> NAME of TANK o AGENT(print) OWN <br /> JOF f�lv�—�12-�/� <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />