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UNIFIED PROGRAM CONSOLIDATED FOMW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page of <br /> I.FACILITY IDENTIFICATION <br /> 3 <br /> BUSINESS NAME(Sana as FACILITY NAMES arD'�B7J Ac,-Doing Busine As) <br /> Li / �/l li a- 476 <br /> ADDRESS(For I—I use only) ,/'y�/'�7�t/�-'j(''' LID . <br /> 1 1 I l V f � 1 477 <br /> FACILITY ID# I TANK ID# <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 /> as I <br /> r 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 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 /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN TURE OF TANK OWNER/AGENT DATE, 484 <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />