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Adik <br /> IT�ffFTRD PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION 1 <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page—of <br /> I.FACILITY IDENTIFICATION — <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) —3 <br /> ADDRESS(For local use only) 476 <br /> FACILITY ID# <br /> TAN ID# 477 <br /> C1 I]C �F PC <br /> H.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> 21111The installer has been trained and certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer having education and experience 479 <br /> with underground storage cank installations. <br /> 480 <br /> 9'-'The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> 11 work listed on the manufacturer's installation checklist has been completed. <br /> 482 <br /> �E,2i ie installer has been certified or licensed by the Contractors' State License Board. <br /> The underground storage tank,any primary piping, and secondary containment was installed according to applicable 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> 111. TANK OWNER/AGENT SIGNATURE <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 OWNERIAGENT(print) 485 -TITLE OF TANK OWNER/AGENT 486 <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />