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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDE]RGROUNI) STORAGE TXN-KS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One Page per tusk) <br /> Page of <br /> I.FACILITY IDENTIFICATION '— <br /> BUSINESS NAME(Sz=as FACILM;NAME ar DBA-Dog Bainew.4j) 3' <br /> ADDRESS(For tocol use only) '4`6.- <br /> FACILITY IDN l I• . TAINTK ID 4 477. <br /> 1 <br /> i <br /> H.INSTALLATION <br /> (Check all that apply;) <br /> 47$. <br /> The installer has been trained and certified by the tank and piping manufacturers. 1 <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. <br /> 4d0. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> f <br /> P] All work listed on the manufacturer's installation checklist has been completed. 4e1. <br /> uz. <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 /> I <br /> III.TANK OWNEWAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my know ledge. <br /> SIGNATURE OF 40 �,EN*Tr DATE 4s4. <br /> 2-/CNAME OWNprint) f Lj�,.1c LG's�✓7i�sa t 495. , TIT-LF OF TANK CAVNT (AGEINTTasb. <br /> UPCF W99)Hw•fwrs-c-112 http:!lw-vrw.ueidomorg Rev.01116MO <br />