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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 1 <br /> I FACILMIDENTIFICATION <br /> BUSINESS NAME(same as FACILrrY NAMEor DBA-Doing Business As)" 3. <br /> "' �� el f \2,en � <br /> ADDRESS(For local use only) 476. <br /> FACILITY ID# 1 TANK ID# <br /> F a7477. <br /> IL INSTALLATI€)N . <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 41 <br /> with underground storage tank installations. <br /> 480. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> asi. <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 493. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> (,V1\ tt;� AA �nJ ` .SIC <br /> III TANK OWNEIVAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK O R/AGEN DATE 484. <br /> ^ � <br /> NAME OF TANK OWNER/AGENT(print) 485. TITLE OF TANK OWNER/AGENT 486. <br /> a urr.<i ��lea�,r �Ja - <br /> UPCF(1/99)Hwfwrc-c-1/2 www.unidocs.org Rev.02/16/00 <br />