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Alk 19111k <br /> VII <br /> UNI ED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE one page ertank <br /> Pape Z a Z <br /> 1.FACILITY IDENTIFICATION <br /> a � <br /> BUSINESSNAME(SO"n FALILIT'T NAME a DOWV Bu4nm M)V) c�, �, , r <br /> ADORESS( tical uv aNyJ �1 <br /> /� . w/ LSC;V t4 s L m <br /> TANK ID 1 <br /> FALILMY 100 <br /> a.INSTALLATION <br /> (Cheek all thaf apply) <br /> 4d1( QB <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 +Ts <br /> experience with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> +ea <br /> All work listed on the manufacturers installation checklist has been completed. <br /> 481 <br /> • The installer has been certified or licensed by the Contractors'State License Board. <br /> +Bz <br /> Vf <br /> The underground storage tank, any primary piping, and secondary containment was installed according to +m <br /> ards and written manufacturer's installation procedures. <br /> applicable voluntary consensus stand <br /> Description of work being certified: <br /> i <br /> III.TANK OWNER/AGENT SIGNATURE <br /> I Cl,IKy INI Ina+�M�w•Ibn pvNEeO nx N UW�nC AtpA�IA to Mt EO+I W my NP.MGW. +M <br /> SIGNATUq pE TANS( E T DATE <br /> _ +e3 <br /> NAME OF TANK OwNEA/A ( p R <br /> +BS TIE OF TA <br /> 0 LA <br /> Formerly SWRC9 Form C <br /> UPCF(1/99) <br />