Laserfiche WebLink
.Jun 09 04 10:34a Care Brown 1209' 461-6342 p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(one page per lank) <br />Nee <br />L FACILTlY IDENTIFICATION <br />t. <br />BUiMMS NAME tgam-PACD.rrYNA Ew DOA -Doing tuna+tit <br />C Iti �v-,rt I,- (il ¢12 r v N <br />aw. <br />ADDRESStrn11�...:owy) <br />© W. C° a v- zY` U) <br />nn <br />tQ <br />t 'fANK IDp <br />FACIl.I'CY II)N ,p 0 0 p✓ % �S �J' 3 <br />l� <br />II. INSTALLATION <br />_ <br />(Check all that apply) <br />ava <br />❑ The installer has been trained and certified by the tank and piping manufacturers. <br />❑ The installation has been inspected and rectified by a registered professional engineer having education and experience <br />a r� <br />with underground storage tank installations. _ <br />neo <br />❑ The installation has been inspected and approved by the Unified Program Agency. <br />a: <br />W All work listed on the manufacturer's installation checklist has been completed. <br />a»� <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 />W <br />voluntary consensus standards and written manufacl rer's installation procedures. <br />Description of work being certified: ( t� 7s <br />` <br />e\ -e. 6 1a ee ear° ej(lST N y T e <br />✓�eot <br />7-4 <br />V cv�J 0 V-G�c f'� �,/ e <br />5 <br />A /� �V- VC-fJ [mien! OlY�yv G <br />t� <br />LIL TANK OWNEWAGENT SIGNATURE <br />I certify that the injor=ation provided herein is Dae and accurate to the hese of my kno»tedge. <br />e <br />SIGNATURE 7'AN AGB <br />DATE <br />' <br />(taint) <br />N TANK�C <br />.AENT <br />TITLEOFTANYEDgW <br />UPCF(1199) Ilwrw r -c-12 http:/Iw .eoida org Rev. 02116100 <br />