Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page <br />of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (sameas CMY NAME or DBA — Doing Business As) <br />: <br />3. <br />oCJeQ0, <br />ADDRESS (For local use only) <br />476. <br />9 B 7 4 cv G-i <br />FACILITY ID# l TANK ID # <br />477. <br />H. INSTALLATION <br />(Check all that apply) <br />478. <br />The installer has been trained and certified by the tank and piping manufacturers. <br />The installation has been inspected and certified by a registered professional engineer having education and experience <br />479. <br />with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />480. <br />[/]'All work listed on the manufacturer's installation checklist has been completed. <br />481. <br />The installer has been certified or licensed by the Contractors' State License Board. <br />482. <br />[�f' The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />483. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />Z�� ►1 �� b v�lCcst ©,^ �� � <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 />SIGNATU <br />DATE <br />484• <br />Io i� <br />NAME OF TANK O ER/A T (print) 485. <br />TITLE OF TANK OWNEWAGENT <br />486. <br />" eta ft-&K� 1, <br />1 C, s PC'. <br />UPCF (1/99) Hwfwrc-c - 1/2 www.unidocs.org Rev. 02/16/00 <br />