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19255517888 Main Fax ig GETTLER RYAN INC 1:30 a.m. 05-16-2007 2/2 <br /> 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 /> 3. <br /> BUSINESS NAME(Same asFACILITY NAME or DBA-Doing Business As) <br /> AR ca 476 <br /> ADDRESS(F«local use only) `�, <br /> "3'I I pse n-1+ Te e /vI a,, c Com- , CA <br /> FACILITY ID# 1 TANK ID# an. <br /> oZD <br /> IL 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 /> eso. <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 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> — onI 05 GC <br /> vas r� � <br /> III.TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to be f my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE ase <br /> NAME OF TANK OWNER/AGENT(pri ) _ 485 TITLE F TANK OWNERIAGENT 486 <br /> L 1" <br /> 11PCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />