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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per <br />tank) <br />Page <br />_ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) <br />3 <br />ADDRESS (For local use only) <br />476 <br />FACILITY ID# <br />l <br />TANK ID # <br />an <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 />aso <br />❑ All work listed on the manufacturer's installation checklist has been completed. <br />asl <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 />III. 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 <br />DATE <br />484 <br />NAME OF TANK OWNER/AGENT (print) 485 <br />TITLE OF TANK OWNERIAGENT <br />486 <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />