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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />I//' <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAMmTY <br />E (Sae as FACILITY NAME or DBA— Doing Bus ess As) <br />3 <br />C J/� i 1 Zoo <br />ADDRESS (For local use only) <br />q76 <br />FACILITY ID# <br />I <br />TANK ID # <br />477 <br />II. INSTALLATION <br />(Check all that apply) <br />[�C-The installer has been trained and certified by the tank and piping manufacturers. <br />478 <br />Rl"The installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />h underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />qao <br />All work listed on the manufacturer's installation checklist has been completed. <br />qal <br />The installer has been licensed by Contractors' <br />qaz <br />certified or the State License Board. <br />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 />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 MENT <br />DATE <br />qaq <br />NAME OF TANK GE print qas <br />TITLE OF TANK OWNER/AGENT <br />qac <br />I//' <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />