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FIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page _ of_ <br /> I.F C41LIT1(.IDENTIFIC TION . <br /> 3 <br /> BUSINESS NAME iSame as FACILITY N�A,ME,or DBA—Dolr/�yBuainaea As) <br /> 478 <br /> ADDRESS(For local use only) <br /> R53v <br /> FACILITY ID# TANK ID# 477 <br /> lit-TITI 111 <br /> LAL <br /> tyCl'S'I b'7 <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 /> Oaf <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 /> III. TANK OWNER/AGENT,S GNATURE <br /> I certify t t e in ffnatio provided herein is true and accurate to the best of my knowledge. <br /> SIG TUR WNER/AGENT 494 <br /> D <br /> AME l WNER/AGENT int) 4e5 TITLE OFT OWNER/AGENT 49e <br /> UPCF (1/99 revised) Formerly SWRCB Form C <br />