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Atr 1'7.% 12:53p Sandra Barnhart 2098458586 p.2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF CON PLIANCE *e PW per raox) <br /> L FACILITY IDE CATION <br /> BUSINESS NAME(sme as FAcrLrfy MARIE or DBA—Doing Bim.A,) 3 <br /> u <br /> ADDRESS(ratroml 1•i •J�.�1^'(� �+ 4% <br /> K"• • ` ° r <br /> FAcu-"7 ID4 II TANKID# 497 <br /> i <br /> IL INSTALLATION <br /> (Check all that apply) <br /> El The installer has been trained and certified by the tank and piping mantri`aeturers air <br /> ❑ The installation has been inspected and certified by a regiswed professional engineer having education and experience 479 <br /> with underground storage tank installations. <br /> The installation has been inspected.and approved by the Unified Program Agency. eau <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> , <br /> The installer has been certified or licensed by the Contractors'State License Board. arc <br /> The underground storage tank,any primary piping,and secondary containment was installed according to applicable 483 <br /> voluntary consensus standards and written manufactwer's installation procedures. <br /> Description of work being certified: <br /> �c� t� Ll� g ® eco- b <br /> e <br /> L&CX c COQ <br /> HL TANK OVeMRIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge.. <br /> SI ATUREOFTAT CQWNERJVr iT � I DATE Wore <br /> NAME OF TANK OWNEWAGENT(print) 485 =E OF TANK OWNER/AGENT ase <br /> UPCF{1199 revised) 14 Formerly SWRCB Form C <br />