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UNIFIED PROGRAM CONSOLIDATED FORM <br />CERTIFICATE OF COMPLIANCE <br />(one page per tank) <br />Page _ of _ <br />I'. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACI[UTTYNAME or OBA - Doing Business As) <br />yDSEr%(r S l 6U <br />ADDRESS (For focal use only) <br />Wo t;. 95336 <br />FACILITY ID #n 1 TANK III <br />t 3s ® V! S2� <br />II. 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 />I9 All work listed on the manufacturer's installation checklist has been completed. <br />(� The installer has been certified or licensed by the Contractors' State License Board. <br />OF 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 />I III. TANK OWNERIAGENT SIGNATURE <br />I certify that the information provided herein is true and accurate to tie best of my knowledge. <br />SIGNA R F TANK OWNER/AGENT GATE i <br />NAME OF TANK OWNERIAGENT (pnnq TITLE OF TANK OWNERIAGENT <br />CUPAFORMS (4/99) Fortnerty SWRCB Form C <br />