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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of, <br /> I. FACILITY IDENTIFICATION <br /> $USMSSNAME(Sn a9FACn,r1`YNA)% or DBA-Doingg <br /> ADDRESS(Fartacaluse only) Z� <br /> 477. <br /> FACUTl'ID# TIT�AJNI—K IW <br /> L'i <br /> If.INSTALLATION <br /> (Check all that apply) <br /> 476. <br /> ❑ The installer has been trained and certified by the tank and piping manufacturers. <br /> 474. <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 490. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> as t. <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> 462_ <br /> ❑ The installer has been certified or licensed by the Contractors'State License Board. <br /> ❑ 483. <br /> The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNERIAGENT SIGNATURE <br /> I certify that the'information provided herein is true and accurate to the best of my knowledge. <br /> as4, <br /> SIGN URE OF TAK O ERIAGENT DATE <br /> NAM F TANK O RI GE T(print) <br /> aas. TITLE TANK OWNS AGENT aa5. <br /> PA�77 WA-h)01 <br /> nP� <br /> UFCE(1199)Hwfwrc-c-1I2 <br /> b /lwww.unidocs.org Rev.02/16/00 <br />