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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 FACIl.rrY NAME or DBA—Doing Business As) 3. <br /> J 0r6) �- <br /> ADDRESS(For local use only) 476. <br /> Z) #p s t- &D ,u0410 S-4 <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 /> aao. <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 abs, <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> WHILE CONDUCTING A SCHEDULED TRI-ANNUAL SB 989 SECONDARY <br /> CONTINMENT TESTING OF THE UNDERGROUND STORAGE TANK SYSTEM IT WAS <br /> NOTED THAT A SECONDARY CONTAINMENT PIPE FOR THE PRIMARY TURBINE <br /> SUPPLY LINE WAS CRACKED. THE CRACK EXTENDED FORM INSIDE THE SUMP TO <br /> APPROXIMATELY 4 INCHES OUTSIDE THE SUMP. FURTHER INVESTIGATION <br /> REVEALED THAT A SECONDARY CONTAINMENT PIPE FOR THE PRIMARY TURBINE <br /> RETURN LINE WAS ALSO CRACKED IN AN ALMOST IDENTICAL MANNER. <br /> REPAIRS WERE MADE AND ALL APPROPRIATE TESTING WAS CONDUCTED AND <br /> THE SYSTEM WAS RETURNED TO NORMAL OPERATIONS. <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 /> SIGNATOF TANK O DATE 484. <br /> ER/AGENT <br /> 0712010T <br /> N <br /> AF TANK OWN R/AGENT(print) 485_ TITLE OF TANK OWNER/AGENT rash. <br /> ls� Z,0 RaJ n� <br /> asp <br /> UPCF(1199)Hwfwrc-c-1/2 www.unidoes.org Rev.02/16/00 <br />