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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 /> L FACILITY IDENTIFICATION <br /> 3. <br /> BUSINESS NAME(Sarno as FACILITY NAME or DBA-Doing Business As) <br /> T S 476. <br /> ADDRESS(For local useody) <br /> I an. <br /> FACILITY 1D# TANK ID# <br /> C <br /> 7M <br /> IL INSTALLATION <br /> (Check all that apply) I <br /> I <br /> 478. <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> 479 <br /> [��pp <br /> Tlle,installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 480_ <br /> 14 The installation has been inspected and approved by the Unified Program Agency. <br /> 4s1. <br /> [kj 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: r\6 <br /> C) . S rv� .7 N 7 v���t cw A`�L �'��4 2 S I,A SS`r. �• <br /> _vj� <br /> ��S �nS'{.rI�S I►a <br /> is e N C . . s✓ �,�a R oa u c.; Z� m A 51 ` A.ti a S c L a•-�A <br /> 02 ���-� E J5 vl—: n� L�n�S A� �/';a� a2 C'2: rv�r�'Z.2..\ ��,� S.t.w•.�r�2�� a.�.d <br /> �2 oclvt�` L' � zs v2 'I ��� % �; >�L. tau Vrat>vcZ ti ..�z <br /> Z <br /> III. TANK OWNERAGENT 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 C'l 'TG b C_r"` =rte L�o. P&TE <br /> NAME OFT OWNERIAGiNr(Print) C L T E i✓ C u,,�n a c7 495 <br /> --7XLE OF TANK OWNER/AGENT�) -1 E �� CF,, <br /> � <br /> � <br /> UPCF(1/99)Ilwfwrc-c-1/2 <br /> http://www.unidocs.org Rev.02/16/00 <br />