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Adak <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (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 /> Fremont Shell <br /> ADDRESS(For local use only) 475. <br /> FACILITY ID# 1 TANK IID# 477. <br /> € c <br /> II.,INSTALLATICI`N <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 /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 482. <br /> ® The 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 /> Installation of a complete new UST system,including tanks,piping and dispensers. <br /> III: <br /> TANK ,AGENT SIGNATURE . <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT"TANKO <br /> A e-- DATE 484. <br /> 4/18/05 <br /> NAME /AGE (print) 485. TITLE OF TANK OWNER/AGENT 485. <br /> Michael E.Walton Contractor <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidocs.org Rev.02/16/00 <br />