Laserfiche WebLink
�vr +.vv r •+..+. iv: av rears 4"400]433 bit; EMU 2002/003 <br /> -A k <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 /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DDA--Doing Business As) 3 <br /> AM <br /> ADDRESS(For beat use only) 476. <br /> r� <br /> IjC7 17 t6T. <br /> FACILITY ID# ITI I I _I t• 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 g <br /> d stora a 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 applicable 463• <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNERIAGENT SIGNATURE <br /> I certify that the infontnation provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF NK O: R ENT DATE 484 <br /> -NAME-OF TANK R/AGENT(print) 485• TIT E OF TANK OWNER/AGENT 486. <br /> UPCF(1/99)Hwfwrc-c-1/2 www.unidoes.org Rev.02/16/00 <br />