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UNIFIED PROGRAM CONSOLIDATED FORM <br />CERTIFICATE OF COMPLIANCE <br />(one page per tank) <br />Page _ of <br />1. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same ascFA�CIIUTY NAME or OBA - Doing Busktess As) <br />Y050^(T,;� Jf1M(k <br />ADOR,gSS (For loeal use only) <br />3° �o5�r� G� 5533 <br />FACIUTY ID 0 1 TANK IO # <br />1 2 3 � O�ISSI Y <br />11. INSTALLATION <br />(Check all that apply) <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 <br />experience with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />All work listed on the manufacturers installation checklist has been completed. <br />The installer has been certified or licensed by the Contractors' State License Board. <br />I8' The underground storage tank, any primary piping, and secondary containment was installed according to <br />applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br />work being certified: <br />III. TANK OWNERIAGENT SIGNATURE <br />1 certify that the infomfation provided herein is We and accurate to the best of my knowledge. <br />SIGNA OF ANKOWNER/AGENT <br />,� <br />DATE t <br />q-ze <br />NAME OF TANK OWNER/AGENT (pnnt) <br />6- �i22rk� <br />TANK OWNER/AGENT <br />CUPAFORMS (4/99) Formerly SWRCB Form C <br />