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UNIFIED PROGRAMCONSOLIDATED FORM <br />CERTIFICATE OF COMPLIANCE <br />(one page per tank) <br />Page _ of _ <br />I'. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACIUTY NAME or DBA . Doing Business As) <br />Y oz ww I j't 5 I4�L <br />ADDRESS (For local use only) <br />1330 e . YJ.%v*tvc A-ve paw * gS31� <br />FACIUTY ID fl I I I 'Y. 1 I TANK ID # ®� <br />H. 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 manufacturer's installation checklist has been completed. <br />The installer has been certified or licensed by the Contractors' State License Board. <br />19 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 />Ill. TANK OWNERIAGENT SIGNATURE <br />I ceroty that a infonnadon provided herein is true and accurate to the hest of mY knowledge. <br />SIGN TANK OWNER/AGENT <br />DATE <br />9 -Zt •�� <br />NAME O TANK OWNER/AGENT (print) <br />� G ��zzlNf <br />TITLE OF TANK OWNER/AGENT <br />CUPAFORMS (4/99) Formerly SWRCB Forth C <br />