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UNIFIED FROG CONS IDATE FORM TANKS <br /> UNDERGROUND STORAGE TANKS-- INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per Inns) <br /> Pas:—.r— <br /> 1.FACILITY IDENTIFICATION <br /> 3 <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing B"nw Ast <br /> S H E—�— LIU 4" <br /> ADDRESS(f«Ioca�) I S TO c )c--T a <br /> 17 ' TANK ID# 477 <br /> FACILITY ID# <br /> I1.INSTALLATION <br /> (Check all that apply) <br /> 476 <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> ® The installation has been inspected and certified by a registered professional engineer having education and experience 179 <br /> with underground storage tank installations. 490 <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 been completed. <br /> asp <br /> e installer has been certified or licensed by the Contractors' State License Board. <br /> 493 <br /> The underground storage tank,any primary piping,and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturers installation procedures. <br /> Description of work being certified: <br /> III. TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best off my knowledge. <br /> 4$1 <br /> SIGN&TURI&OF TANK OVfNERUAGENT DATE �y <br /> ' L � �7 0 <br /> NAME OF TANK O WAGEN I(print) <br /> tg5 TITLE OF TANK OWNER/AGENT 486 <br /> J®.E D>�lv�TQ�N. ® '^/N F rZ <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />