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D PROGRAM CONSOLIDATED FOTM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACB.TTY NAME or DBA—Doing Business As) 3 <br /> 4t 7 <br /> ADDRESS(For local use only) 476 <br /> FACILITY ID# l TANK ID# 477 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478 <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 experience 479 <br /> with underground storage tank installations. <br /> 480 <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> D1--All work listed on the manufacturer's installation checklist has been completed. <br /> asz <br /> 9---�Tbe 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 /> i <br /> I <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> I <br /> SIGNATURE OF TANK OWNER/AGENT DATE 484 <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNER/AGENT ash <br /> I rt <br /> G C�e, e`• t Z��:':s � �-` °.�.p4y. � A,o, _ 3''L '�F��' 'v .r. � _�+ °.!'�'.,' '" - <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />