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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 />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) <br />3. <br />ADDRESS (For local use only) R�, <br />476. <br />FACILITY 11-777 <br />boy <br />3�(�(D5�5��� <br />ID # <br />477. <br />II. INSTALLATION <br />(Check all that apply) <br />a7& <br />KThe 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 />aso. <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 />ass. <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />_frit5TALL A—ir'oq ®1= O()S 1 A,.�> A•SSOC( AeT" EG,r0iii <br />pIPLiL('., VS T -re C0 L7- A,-, KI <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 />11 <br />SIGNAT O K O E A <br />DATE <br />asa. <br />NAME 0F TANK O E print) 485. <br />TITLE OF TANK OWNER/AGENT <br />486. <br />(CA A-i,z. F-, A LT—" <br />F ►-" (b r,, - , UIA c'o-,Q <br />UPCF (1/99) Hwfwrc-c -1/2 http://www.unidocs.org Rev. 02/16/00 <br />