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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of_ <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME tsmnm FACUJry DBA- osam ), 3. <br /> ADDRESS(Forba monly) 476. <br /> AI S Dc n-1 .4 <br /> FACILITY OJN <br /> 1. TAMC ID N an. <br /> IL INSTALLATION <br /> (Check all that apply) <br /> ars. <br /> [f 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 4". <br /> with underground storage tank installations. <br /> 4ao. <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 applicable 483. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN A )F TA1 lC O DATE 484' <br /> NAME F R/ ENT(print) <br /> 4m. TITLE OFT OWNS N1' aeb. <br /> 60- <br /> UPCF(1/99)Hwlwrc-c-1/2 http:/Iw .midws.org Rev.01✓16M <br />