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04/09/2004 15:12 2094GB3433 <br />FIFTH FLDOR <br />If <br />PAGE 02 <br />-, 1 ; ' UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />1 CERTIFICATE OF COMPLIANCE (ono page pe, mN) <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (S.m uFAr2LM NM aOaA-Dams B— A9 .. _. <br />r `,a <br />ADDRESS nvr lora.,. amy, <br />.76 <br />-5 8 C`na� `, sou c K t r� <br />FACILITY ID# <br />I <br />TANK ID n <br />an <br />11. INSTALLATION <br />(Check all Chu apply) <br />❑ The installer hes been trained and certified by the tank and piping manufacturers. <br />fl <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />a" <br />with underground storage tank installations. <br />Lj The installation has been inspected and approved by the Unified Program Agency. <br />4V0 <br />E] Ali work listed on the manufacturer's installation checklist has been completed. <br />xi <br />The installer has been certified or licensed by the Contractors' State License Board. <br />ex <br />❑ The underground storage tank, my primary piping, and secondary containment was installed according to applicable <br />4B1 <br />voluntary consensus standards and written manufacturer's installation procedures. _ <br />Description of work being certified: <br />`1- <br />— IV O 7—,4 N I<. /Z F P 1 c E h1 E N — <br />2e An a v 4� a x r S-Pa7 F: (f 't- vo-6 or 0 u C- <br />- <br />FMIrKtsl. f LA> ST DPW r--, V, F fl <br />FM <br />A -Iv a: J o /> a v- J3 IL C'J' <br />III. TANK OWNERIAGENT SIGNATURE <br />14ertify Net the infortnetian Provided hvcin istrueandamuratetothe bestofmy lmo lcdge. <br />SIGNATURE O ANK WNE DATE <br />6+..- 1 2) — T <br />NTITLEOTANKOWNER/AGE�NT <br />Q fT <br />M6 <br />LN <br />iC a fJ <br />UPCF (1199 revised) 14 1 Formerly S WRCB Form C <br />