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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- LNSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> Pap-of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAW(sme a Fro¢n'YXaM¢a DBA-Dmgamiam M) '. <br /> ADDRESS(Fatoatuxamy) 15 <br /> r(� Ll S S z (i � <"T-OCL tin co <br /> FACILITY IDN r TANK ID 4 <br /> t I S <br /> 6o,02a7 <br /> H.INSTALLATION <br /> (Check all that apply) <br /> I <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 ug <br /> with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> ash. j <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> ua. <br /> ® The installer has been cenified 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 /> voluntary consensus standards and writter,manufacturer's installation procedures <br /> Description of work being cetified: <br /> I <br /> I <br /> I <br /> I <br /> -J <br /> IIL TANK OWNERIAGENT SIGNATURE <br /> I certify that the tafortnstion provided herein is true and ecctuate to the best of my knowledge. <br /> SIG F TANK AG DATE <br /> I <br /> NAME OFF TANK OWNER/ E (print) J,19{/lace Li,/c%Jy ,��491. TITLF,OF T.k\TK OWNER <br /> C.C> C /�'Y' �it�! %/'GIMr^r•A9 '.c'./ ! �' Qf l' G3' <br /> UPCF(1/94)Hwfw c -I/2 http://w".unidm.�org Rev,02116MO <br />