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U *ED PROGRAM CONSOLIDATED WM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> one e e eT tank) <br /> Page 0( <br /> 1.FACILITY IDENTIFICATION <br /> 0 <br /> BUSINESS NAME(Same as FACIUTY NAME a OBA-OW9 BuAl Aal <br /> 1 V /!� '� 476 <br /> ADDRESS(RW aW we-NY) <br /> I `i s "i L S-0 ID QC f-b J Z <br /> FACILITY ID# 1 T KID# 477 <br /> i <br /> It. INSTALLATION <br /> (Check all that apply) <br /> ¢q The installer has been trained and certified by the tank and piping manufacturers. 476 <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and 679 <br /> experience with underground storage tank installations. <br /> ,❑ The installation has been inspected and approved by the Unified Program Agency. +� <br /> All work listed on the manufacturer's installation checklist has been completed. 481 <br /> ¢J� The installer has been certified or licensed by the Contractors' State License Board. +� <br /> •ar The underground storage tank, any primary piping, and secondary containment was installed according to +s� <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> r sPL, <br /> 3, 060 5 , 600 , , Cllr/I"'so / .)7tD.1 , Ar, //� r, <br /> -�-2 (2c outC. 42� ul �maI <br /> III TANK OWNER/AGENT SIGNATURE <br /> I cantly Nal Ise inigtmedan pluMCeA em a ne and a 18 IO Ne east Of my maM ge. <br /> SIGNATURE OF TANK ENT <br /> GATE 404 <br /> Z Z .e6 <br /> OF TANK D'A'NE A NT(POM) 465 TITLE OF TANK AGE <br /> I I M -jLli t f}G�� R- ow C-yL <br /> UPCF(1/99) Formally SWRCS Foml C <br />