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IL, <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 /> — <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACUJNor DBA-Doing Busims AS) 3. <br /> l <br /> ADDR.ES S(For local use only) 476. <br /> FACILI�Y�Dil� 1 ANK ID# an. <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478. <br /> 1 Pe installer has been trained and certified by the tank and piping manufacturers. <br /> j The instaiiation has been inspected and certified by a registered professional engineer having education and experience 47' <br /> with underground storage tank installations. <br /> YThe installation has been inspected and approved by the Unified Program Agency. aeo <br /> agt. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> asi. <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 /> cri tion of ork being certified: <br /> ,4411 <br /> A&P <br /> ct a4 <br /> IQ.TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herejn is true and accurate to the best of my knowledge. <br /> SIGNAT T. O WN£RIAG' T DATE <br /> asa_ <br /> NAME OF TANK OWNER/AGENT ) 985• TIT F TANKgqOWMER/A NT 486. <br /> 1'Z'�^` 'lid <br /> UPCF(1/99)Hwfwrc-c-I/2 http://www.anidocs.org Rev_02n6/00 <br /> E -d 0irE9 T 9bG02 ou I sjojoeJ4tJ00 AI 84 t I9 esb :BO LO Ta o9a <br />