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09/10/2007 MON 16: 26 FAX 2094683433 SJC EHD 0002/003 <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 /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA--Doing business As) 3. <br /> E' <br /> ADDRESS(For local use only) 476 <br /> FACILITY IDH 17K ID# 477. <br /> h a <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ❑ The installer has been trained and certified by the tank and piping manufacturers. 476. <br /> ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479' <br /> with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. 460. <br /> All work listed on the manufacturer's installation checklist has been completed. 481. <br /> ® The installer has been certified or licensed by the Contractors' State License Board. 432. <br /> ❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable 463' <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge_ <br /> StGNA RE OF NK O ER GENT DATE 464. <br /> 7 <br /> AM ANK OWNER/AGENT(print) 485• TITLLT OF TANK OWNER/AGENT 486. <br /> ..r <br /> UPCF(1/99)Hwfwrc-c-1/2 mmunidoes.org Rev.02/16/00 <br />