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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 _ <br />of_ <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACII.rrY 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 />477• <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 />❑ 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 />480. <br />❑ The installation has been inspected and approved by the Unified Program Agency. <br />❑ All work listed on the manufacturer's installation checklist has been completed. <br />481. <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 OWNER/AGENT <br />486. <br />UPCF (1/99) Hwfwrc-c -1/2 http://www.unidocs.org Rev. 02/16/00 <br />