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cfl <br /> SK Sal, l 3 UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS — INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME nr DHA—Dome Busu-,s As) <br /> QS Cees <br /> ADDRESS(For local use only) 476 <br /> 'aL�4 Y t04(-e c &j t Low Lo CU CIA <br /> FACILITY ID# I l I TANK ID# an <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ® The installer has been trained and certified by the tank and piping manufacturers. 47e <br /> The installation has been inspected and certified by a registered professional engineer having education and experience 479 <br /> with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. aso <br /> All work listed on the manufacturer's installation checklist has been completed. asl <br /> The installer has been certified or licensed by the Contractors' State License Board. asz <br /> The underground storage tank any primary lPi ing,and secondary containment was installed according to applicable aa' <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> o+ Uht( C.1J *-C,,6o icta. <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 /> SIGNATURE OF TANK OWNEJUAGENT DATE/ 9 asa <br /> L/. t F �� 0 <br /> NAME TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />