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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 /> BUSINE��SttS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> ADDRE (For tical use only) <br /> 476. <br /> IU IF- i t'Zt—� `TRC - 1 TP-AC- v <br /> FACILITY ID# <br /> I. TANK ID# 4n. <br /> AGT"i r-)p t-A F. €.L <br /> H.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 /> ago. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 481. i <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> 482. <br /> Er The installer has been certified or licensed by the Contractors'State License Board. <br /> [t 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 /> i <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 /> I <br /> SIG F TANK OWN DATE °$' <br /> NAME OF TANK OWNER/AGENT(print) 485• TITLE OF TANK OWNER/AGENT 486 <br /> UPCF(1/99)Hwfwre-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />