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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(Sant az FACR1TY NAME m DBA-Doing Business As) <br /> t C7 C tL 2 S tZ E S 476. <br /> ADDRESS(For local use only) <br /> 4T7 <br /> FACILITYID# I TANK ID# <br /> , C f--j) I I �[=- — <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> &/Me,installation has been inspected and certified by a registered professional engineer having education and experience 479 <br /> with underground storage tank installations. 480. <br /> X The installation has been inspected and approved by the Unified Program Agency_ <br /> 481. <br /> Q All work listed on the manufacturer's installation checklist has been completed. <br /> asz. <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: Q . , <br /> _.N S—I q I I CA Ncw tN . C> S ,v� .7� Sl,�SS <br /> Q�•S�.�Y15'.rr1.S � i N `i S � �. v • N L •� .1 L 1 .,.�a� t��L�Ja rv,-r.i (t'Z� M A L1.� A..,cl S-c._t,L•�1 P <br /> �� D2 �'2 rv.A2.` A1c� Sc.w•.�A, �� a d <br /> noc L n�S AAA V . <br /> �2vclvti,i L: ��� :-v2 l tam ��;S�L. tau v'Y-11vcz L� ..Lz tLE4�.:l� c <br /> Z <br /> s�e n 9:-,"-C . <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 /> 484. <br /> SIGNATURE OF TANK OWNER/AGENT G-1.•TC-. V C:L'� `=y�c-Z v. ,QAjE <br /> OWNER/AGENI Tint f E t✓ C n a 485 �T LE OF TANK OWNER/AGENT 1~y.� 6x'49 <br /> NAIv1E OFT (print) L• i <br /> V-) <br /> t7 W 22o w C1 ES <br /> h ://www.nnidocs org Rev.01/16/00 <br /> UPCF(1/99)1lwfwwre-c-1/2 ttP <br />