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Ankh� �Q <br />UPCF (1/99) Hwfwrc-c -1/2 http://www.unidoes.org Rev. 02/16/00 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS — INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(One page per tank) <br />Page \ of <br />L FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACHJW NAME or DBA — Doing Business As) <br />3. <br />ADDRESS (For local use only) <br />476' <br />1 i 5 i L s a u; S c v'cr-- x'1'1 ; De c, S <br />FACILITY ID# <br />T <br />[—FI <br />TANK D # <br />an. <br />II. INSTALLATION <br />(Check all that apply) <br />478. <br />® The installer has been trained and certified by the tank and piping manufacturers. <br />[JVW installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />with underground storage tank installations. <br />Oso. <br />The installation has been inspected and approved by the Unified Program Agency. <br />481. <br />® All work listed on the manufacturer's installation checklist has been completed. <br />ase. <br />® The installer has been certified or licensed by the Contractors' State License Board. <br />The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />43 - <br />3voluntary <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />I &L� A,C) Srn. i7j)Lti�)c 1-v�tt ►',, <br />p-T—lLiS1C}1y1Cs7 <br />61Y3�s <br />E �I i S ►� G T fl k s o IJ) <br />Rcz.ns�a��zd <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 O�OWNE AG <br />DATE q <br />484. <br />NAME OF TANK OWtjER/ GENT (print) 495. <br />TITLE OEJANK OWNER/AGENT <br />486 <br />UPCF (1/99) Hwfwrc-c -1/2 http://www.unidoes.org Rev. 02/16/00 <br />