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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 FACBdTY NAME or DBA — Doing Business As) 3. <br />G -'v <br />ADDRES S (For local use only) 476. <br />i 1 5 i L S� u_ : c 1'1 !- c: s <br />FACILITY ID# <br />1. <br />TANK D # 47 <br />K INSTALLATION <br />(Check all that apply) <br />478. <br />[) The installer has been trained and certified by the tank and piping manufacturers. <br />DWO installation has been inspected and certified by a registered professional engineer having education and experience 479. <br />with underground storage tank installations. <br />480. <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 />482. <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 483. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />—T—/VS1��►lEs7 <br />IVW -c� i e-,2 <br />NY` Ate; <br />+� ,-• <1. V' $1.,�\i� i2..-�,.. <br />�y/� t\t V U J1 ust ` _ • m A SL C,c.,,...�.• <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 />SI OFT OWNER/ <br />DATE /x 494.• <br />NAME OF TANK OWNER/AGENT (print)) 485. <br />TITLE OF TANK OWNERIAGENT ash. <br />UPCF (1/99) Hwfwre-c -1/2 http://www.usidoc&org Rev. 02/16/00 <br />w <br />