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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Page <br />of _ <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME Same as FACILITY NAME o DBA— Doing Business As) <br />3 <br />ADDRESS (For local use only) <br />T -L10 <br />7G <br />FACILITY IDI <br />TANK ID k <br />477 <br />117-4.2.13 <br />II. INSTALLATION <br />(Check all that apply) <br />478 <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 <br />479 <br />with underground storage tank installations. <br />4110The <br />installation has been inspected and approved by the Unified Program Agency. <br />LJAll work listed on the manufacturer's installation checklist has been completed. <br />481 <br />Theinstaller has been certified or licensed by the Contractors' State License Board. <br />482 <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />483 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />VVI <br />T�s�all -rcOrP moa -4 - <br />cola <br />III. TANK OWNER/AGENT SIGNATURE <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNAT TANK QYJI ,R/AGENT <br />DATE: <br />a84 <br />bEO1,-' <br />�' -�!'1 <br />1113010-) <br />NAME OFNK OWNER/AGENT (print) 495 <br />TH LE OF TA K OW ERWIFNIT <br />486 <br />it, SDv� <br />II K 11c%vta Y <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />