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MTH <br /> PFr417/SFRV10ES <br /> PUNI: MD PROGRAM CONSOLIDATED FORM <br /> "TANKS <br /> UNDERGROUND STORAGE TANKS- INSTALLATION <br /> CERTIFICA'T'E OF COMPLIANCE <br /> (One page per lank) <br /> Page_or <br /> --- <br /> L FACILITY IDENTIFICATION <br /> BUS NESS NAAE(S.a .FACII.ITYNAW-DHA—Dhe., 3. <br /> ADDRESS(Farlocaluscooly) �^ , , ! 976' <br /> ALAI <br /> FACILITY IN TANK ID# 477. <br /> q 71 <br /> II.INSTALLATION <br /> C <br /> (Check all that apply) <br /> c installer has been trained and certified by the tank and piping manufacturers. 479. <br /> 2__�The installation has been inspected and certified by a registered pro&ssionai engineer raving education and experienee 477 <br /> with underground storage tank installations. <br /> 4W.ZThe installation has been inspected and approved by the Unified Program Agtmcy. <br /> 4s t. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors'State License Board_ 492. <br /> [�] The underground storage tank, any primary piping, and secondary containment was installed according to applicable 4n <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> ser- tion of work being certified: <br /> Arm <br /> J <br /> �-!7' '� >•v'� Gey-I/� G ��� � .,� -�z��' �?� <br /> /l 'dk�f L�� G� G�/1 l hZ�r It <br /> r O _ ENT SIG N �f'1 <br /> C/Z CZ <br /> I certify that the information provided buein is true and accurate to the best of my knowledge. <br /> SIGN OF TANK OWNERIAGENf LATE � M <br /> I <br /> NPAE OF TANK O-VNMAGENT( 'at 495. TI F TAN OWNER! 'EI I 496 <br /> +�j'� <br /> UPCF(1199)Hwfwct-c-12 bttp;/A ww.uaidomorg Rev.82116/0U <br /> T -d at,EST9j760a OuI 5j0g0e.aqu00 AI aIT i3 db0 s TO LO TZ AON <br />