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Ah <br />Ah <br />low <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page 3 of 3 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doiny Business As) <br />3 i <br />BOr.1FAfLE WIP•fL1LET 3S <br />ADDRESS (For local use only) <br />476 <br />FACILITY ID4 <br />I. <br />TANK IDN <br />+7' <br />03 <br />II. INSTALLATION <br />(Check all that apply) <br />The installer has been trained and certified by the tank and piping manufacturers. <br />yrs <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />"y <br />with underground storage tank installations. <br />® The installation has been inspected and approved by the Unified Program Agency. <br />480 <br />All work listed on the manufacturer's installation checklist has been completed. <br />181 <br />® The installer has been certified or licensed by the Contractors' State License Board. <br />,e. <br />® The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />'81 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />(�tPtsAC% SysTEvt%, r—IL L C s At-ub <br />SPILL Cou-t-p„laEt2.s . <br />III. TANK OWNER/AGENT SIGNATURE <br />1 certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF T*N*QAW+ER/AGENT <br />DATE /' } / 0 3 <br />484 <br />NAME OF TAN*—�AGENT (print) 485• <br />TITLE OF TA-)rHEeYOW R/AGENT <br />J$6 <br />1c t4 As t - UALT04 <br />C OKT-2 AC Tort <br />UPCF (1/99) Hwfwre-c - 1/2 http://www.unidocs.org Rev. 02/16/00 <br />