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r r ' <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) f <br /> Page of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> ADDRESS(For local use only) <br /> FACILITY ID• 1 TANK ID N <br /> 11.INSTALLATION <br /> (Check all that apply) <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 <br /> experience with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> ❑ All work listed on the manufacturer's installation checklist has been completed. <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 <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br /> 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 OWNER/AGENT DATE <br /> NAME OF TANK OWNER/AGENT(prinry TITLE OF TANK OWNER/AGENT <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br />