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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_ k of <br /> L FACILITY IDENTIFICATION <br /> 3. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) <br /> T C tL 2 S o tZE S 476. <br /> ADDRESS(For local use only) <br /> \-2,C�% �. . `•S an. <br /> FACILITY ID# 1 TANK ID# <br /> CL-n. 1=11:[LLE - <br /> IL INSTALLATION <br /> (Check all that apply) <br /> I <br /> 478. <br /> Vj The installer has been trained and certified by the tank and piping manufacturers. <br /> 479. <br /> &A installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 490. <br /> t4 The installation has been inspected and approved by the Unified Program Agency. <br /> agt. <br /> Q All work listed on the manufacturer's installation checklist has been completed. <br /> agz. <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 /> -IL" S7,4!ICA N c,W Ifs . C) . S ,,., .T N +�G t.,�.�1 c I...J A�,L. � ;S'S�� S l�A SS ►n 6 <br /> m C,"L;S-T i AIG -f Ca r.1�S T b N W e f L 1 r4 nS `-= L <br /> r%Sj A�%j,) �y �� n <br /> Th) �S ; NL � ,�c1 Ie4 r��-06 �2� n. An A,� Seca-dP <br /> J,�L -N"A-4- u!_: c L::� <br /> eC �-v2 l iJ� ��IStL . Nv V VA 0 L L� +��s t� E4ti:t� c <br /> Z <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 /> aaa. <br /> SIGNATURE OF TANK O WNER/AGENT r--)—;TC 1,V' C tJ"'`=n LZ° ]ATE <br /> 495 �LE OF TANK OWNER/AGENT E y,�'E\V <br /> NAME OFT O WNER/AGEN I (primo) �L•T fr L V^ C v,,-t n a t7 ' <br /> DZ.J ✓� ;Zo w C1 ES <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidoc&org Rev.02/16/00 <br />