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to _tl <br />Ah AhL <br />11111W 1qW <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page L <br />of 3 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business At) <br />3 <br />O^(y7.-a, A-fLIG6.T 3S - <br />ADDRESS (For local use only) <br />476 <br />1 9' E. G, (2 A a -T- L, -( E 2 n. , T2 Ar C y <br />FACILITY ID# <br />477 <br />IIIjj�III�11]-JTANKID# <br />01 <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 />J7'' <br />with underground storage tank installations. <br />The installation has been inspected and approved by the Unified Program Agency. <br />+ao. <br />All work listed on the manufacturer's installation checklist has been completed. <br />491 <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 />'a' <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />�t(>Ikt(, <ySTF—M 'FILL. I p((zl,u(r, <UWPIC , V�C S A),O <br />r <br />S PiL, �o�-r A,•c�t�s . <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 TAA7i4H�AGENT <br />DATE ' A Q 3 <br />484 <br />NAME OF TAttK-O'tl 11MAGENT (print) 485• <br />TITLE OF `F*N f-6tV'FIER/AGENT <br />496 <br />fCNAI✓ C E. - WA L, —ick <br />C oLur2 .A..c.r o rz <br />UPCF (1/99) Hwfwrc-c - 1/2 http://www.unidocs.org Rev. 02/16/00 <br />