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Ah <br />r_1 <br />IRW <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per lank) <br />Page 2- of 3 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business M) <br />3 <br />Bo�FP.a-E_ HA,4R(eET 3S - <br />ADDRESS tFor local use only) <br />476 <br />/ S' F. (; t2 PS T L # e%L E j2'b . , T2 A e Y <br />FACILITY ID# <br />r• <br />TANK ID N <br />+7' <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 />"y <br />with underground storage tank installations. <br />® The installation has been inspected and approved by the Unified Program Agency. <br />+so <br />All work listed on the manufacturer's installation checklist has been completed. <br />X81 <br />The installer has been certified or licensed by the Contractors' State License Board. <br />4e: <br />(� The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />'83 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />►�tptrtC� SYs rr-_m FtcL svb%ps � UbC C /fir" <br />SPtt-1 CO-cTAr�(�2S . <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 GIANER/AGENT <br />DATE Io <br />+8+ <br />NAME OF AGENT (print) 485• <br />TITLE OF'F*N*1&V"ER/AGENT <br />486 <br />6tC04E, W ALre 114 <br />C90*ct'RA-(.Ton. <br />UPCF (1/99) Hwfwre-c - 1/2 http://www.unidocs.org Rev, 02/16/00 <br />