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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 /> ADDRESS(For local use only) 476 <br /> FAC]LITY 10# �� TANK 1D# 477 <br /> r a <br /> a <br /> zK ro 5:1101�1. .a, <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. 476 <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and 479 <br /> experience with underground storage tank installations. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. 480 <br /> All work listed on the manufacturer's installation checklist has been completed. 481 <br /> The installer has been certified or licensed by the Contractors' State License Board. 482 <br /> The underground storage tank, any primary piping,and secondary containment was installed according to 483 <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> P <br /> 41 <br /> n r ® 1 <br /> Top <br /> t <br /> r -EV <br /> six. � js�5>: ;:;, " �sa.... su�. � .. z in m z ;., t 7:. <br /> q AT <br /> z - s- �! to ,} "",'£ �...,a r: ... Sx s <br /> 1 certify that the information provided herein Is true and accurate to the best of my knowledge. <br /> SIGNAREM TANK OWNER/AGENT DATE 484 <br /> NA T NK ER/AGENT(print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form C <br />