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Jan 21 08 11:24a Bagley Enterprises, Inc 2093675424 <br /> - r p.2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> ---' (one page per78nx) <br /> pap _� L <br /> I.FACILITY IDENTIFICATION <br /> ausiwL.is wcuets•m•nc�DitrtrwMa..oet-meyeu.n•nFs) <br /> nocaess fcarowiur•em'n <br /> i O fs�E t✓ . t+wf cls- F�cc��Gr ��. s-secsaT�--r.�r GA a S z .a <br /> FeMMI). 4 T�NKID• <br /> g.INSTALLATION LSF mLC.147M7¢Nr_ L+x£. Lp-mow=. p ��r�, <br /> (Check all that eppty) <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified bya registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> LtY Alf work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified of licensed by the Contractors'State License Board. <br /> ❑ The underground storage tank,any primary piping,and secondary containment was installed according to <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br /> work being certified: <br /> Ili£_ f336ti£- -,ILa;=C(-1-IN, +'rT=C-3 9—'1 Rei '7-0 -TAE zWS'T73tt H':3zYY ] <br /> 13 VR002L.9.,iS Wrl S7-c (,VAI-r� h•ECHA�-tiZ.N2 2-.-.a�£ t' A i+ <br /> '�F�-f_inC�2 Cid L.LII <br /> 07•.1 'Th jF 6e, Pty C1i,"CST- i-ztl <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> Iwei>v ePRpye.e.an•mi.nuw.b euw.rerowwstar nr.rorwcs•. <br /> 113 <br /> v .Tuaea ru, waDwr are <br /> IUME DiT R wlgCMp.:.x Tt1lE DF T.WM rtF.NCwM1GIN! <br /> C00TR PLTDL/Lis00 cC-U2 1YtCv?aalrl ct(rVpi <br /> CLIPAFORMs(4143) Fwmany StVRCe Form C <br />