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UNIFIED PROGRAM CONSOLIDATED FORM <br /> • TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of_ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Samc as FACILITY NAME or DBA—Doing Business As) 1. <br /> AA CC � <br /> TF G <br /> ADDRESS(For local use only) 476. <br /> FACILITY ID# TANK 1D# 477. <br /> II.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 479 <br /> with underground storage tank installations. <br /> 480. <br /> (� The installation has been inspected and approved by the Unified Program Agency. <br /> 481. <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 482. <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 4R' <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> 17,A S-r A.t.t ,.-rto.4 O F CO t-tEw V S T S: 7—E 4A <br /> III.TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWN AGENT DATE 484. <br /> NAME OF TANK OWNE GEN (print) 485. TITLE OF TANK OWN A EN 486. <br /> )AIC946L E , W A L To N G#4 r A-c fz <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />