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' U NIFIEDP ROG RAM CONSOLIDATEDIAdk <br /> � ORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page of _ <br /> WV '04. <br /> ANA%�'.��„��'rj � ,���:�..j�` ��"� r�.� t a + 'r <br /> K l?fr �%4, f <br /> Ilial'"1l�N�lChllbiDa�bOitiZ'Hgii�hess�Asy ".3�� � s <br /> L_ <br /> ADDR ESS(For local use only) 476 <br /> - C <br /> FACILiT1r ID;# .: 1 dI TANK ID# 477 <br /> 'I1INSTALLATI0N � s <br /> 3 <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. 478 <br /> t 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 /> I, 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 /> 77777-7 <br /> 111.T NK OVIINER% GENTSIGNATURE" <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE 484 <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE bF TANK OVO4ERIAG15NT 486 <br /> :'\7� C.t <br /> PCF(1/99 revised) 8 Formerly SWRCB Form C <br />