Laserfiche WebLink
a— Ask <br /> LW, ffD PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- LNSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per.tank) <br /> Page_of_ <br /> i <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAW(S=v FAc¢m:;XNJEi.D13A-D.6B.;..W <br /> ADDRESS(Fabuto ux Y) _ I <br /> e I Ci C) <br /> FACILITY IDA I TANK ID M � "` <br /> I <br /> U.INSTALLATION <br /> (Check all that appl7) <br /> re <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 /> with underground storage tank installations. <br /> +ec. <br /> rj The installation has been inspected and approved by the Unified Program Agency. <br /> aet. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> uz. i <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> i <br /> The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturer's installation.procedures. <br /> Description of work being certified: j <br /> I � <br /> i <br /> 1 <br /> I � <br /> i <br /> a <br /> f <br /> I UL TANK OWNERIAGENT SIGNATURE <br /> I ceniN that the' herein is We and awutsie to the best of my knowledge. <br /> om]ation p vided _----,I <br /> SIGN F TANi _ DATE tec. <br /> 03 _ <br /> NANE OF TANK OW. GE . (print) 7;�/1 7' y R L {i ws� TIT,LF,OF TANK 0P.7VER% G 165. I <br /> tJPCF(1199)Hwftrr�-V2 http://wme.ueldnee.org Rev.02.!1(i/Mt <br />