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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(Same as FACILITY NAM or DBA-Doing Business As) <br /> I i <br /> R _ CArFS <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 /> 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 413 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> �KSTALIA-T'ioA OF A, COaAPI.E_TE New U ST— S STEtM <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 GEN DATE 484 <br /> NAME OF TANK OWNS GE (print) 485. TITLE OF TANK OWNE GENT ash. <br /> 04 1C0AFEL E A l 'ro4 C m&LT <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />