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01/08/2004 08:23 2094683 FIFTH FLOOR PAGE 23 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(one pageacr tank) <br />Pap <br />101 <br />ADDRESS (For local use orjy) 0* S—t f2 -0E --F s-rc;.c-/c-TWNJ 0j" <br />FACILITY ID# <br />L <br />TANK ID 4 <br />(Check all that opply) <br />911"The installer has been trained and certified by the tank and manufacturers. <br />piping <br />E] The installation has been inspected and certified by a registered professional engineer having education a:ad oxpcnelace <br />with undergrowid storage tank installations, <br />F1 The installation has been inspected and approved by the Unified Program Agermy, <br />71 All work listed on the� nianufacturcr's installation checklist has been completed, <br />211"The installer has been certified or licensed by the Contractors' State License Board. <br />CT-I'The underground storage tank, any primary piping, and secondary containment was installed according to app-icable <br />voluntary consensus standards and written manufacturer's installation procedures - <br />Description of work being certited- <br />77, <br />I certify that the inforinadon provWcd berein i rue! and accorate to the best ofmy knowledge. <br />SIGNATURE OF T OWNEW I�NT <br />DATE <br />03 <br />NAME OF T,A(!��OWNE ACTENT(pnn;)" 485. <br />TITLE OF TA,1 11"IENT <br />