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07IED PROGRAM CONSOLIDATED FORW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of_ <br /> I. - CIL TY IDENTIFICATIO , <br /> 3 <br /> BUSINESS NA (a.-ae FACIL"NAME DSA Doingeualneea As <br /> 478 <br /> ADDRESS(Porloye�yae ony) <br /> FACILITY ID# l <br /> TANK LICD/#a 477 <br /> T��S t�`I►p�i <br /> II. INSTALLATION <br /> (Check all that apply) <br /> 478 <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 479 <br /> experience <br /> 480 <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 482 <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 483 <br /> applicable <br /> Description of work being certified: <br /> I certify that In ation provided herein is true and accurate to the best of my knowledge. <br /> SIGNA R F O� ERIAGENT DATE (^ 484 <br /> AME K WNE AGENT(prin _ / 4� TITLE OF T EP/AGENT aee <br /> UPCF (1/99 revised) Formerly SWRCB Form C <br />