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UNIFIED PROGRAM CONSOLIDATED FORM <br /> • TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank i <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) 476_ <br /> FACILITY ID# 1. TANK ID# 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 /> Oso. <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 /> ase <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 411 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> J-KSTA, .LArtro«f 0A- CCµPLF T"F l�(Eu1 VST SSTE.wt . <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 OWNE GENT DATE 484, <br /> NAME OF TANK OWNE GE (print) 485• TITLE OF TANK OWN E AGEN 486, <br /> t u A-is.L tW 4 L T L .A< 0 fL- <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />