Laserfiche WebLink
0 <br />• <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Page _ <br />of _ <br />1. FACILITY IDENTIFICATION <br />BUSINX NAME (Same as FACM } NAME or DBA - Doing Business As) <br />3 <br />t �£ 3.� <br />ADDRESS (For ]cat use only) <br />476 <br />FACILITY ID# <br />1 <br />TANK ID # <br />477 <br />II. INSTALLATION <br />(Check all that apply) <br />The installer has been trained and certified by the tank and piping manufacturers. <br />478 <br />The installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <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 />481 <br />The installer has been certified or licensed by the Contractors' State License Board. <br />482 <br />The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />483 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />b �EyjOd/L �5`O/7 <br />J'` ;i�JsT//�� %�1��%p'!�' �irJo-�Q.%s`�rYvfi�/` /�a3 f ��/!1-.�5 �✓2�f�r�cT yc �iq�C� //j�f� <br />o <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 />SIGNAT E OF TAN"WNER/AGENT <br />DATE <br />484 <br />_ <br />�^ a3 <br />N OF TANK OWN A/G�ENT (print) 485 <br />TITLE OF TANK OWNER/AGENT <br />486 <br />UPCF (1/99 revised) <br />14 <br />Formerly SWRCB Form C <br />