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I <br />f <br />BU INESS NAME (Same w F, <br />fit. <br />ADDRESS (For l\oc�al use only) `y <br />3 38�V - 1 A <br />FACILITY ID# <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />NAME or DBA —going Busineas As) <br />TANK ID # <br />(Check all that <br />(One page per 1 <br />Page 4-- of <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 />with underground storage tank installations. <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 />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 />voluntary consensus standards and written manufacturer's installation procedures. <br />Desai tion of work bein certified: <br />478. <br />479. <br />480. <br />481. <br />482. <br />483. <br />P g <br />V �A� �Ov A p :Skc -ci� f- Vw& V_ t tn�-!� �'v c� 5 'S i`n 5 <br />�i <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />17 SIGN O <br />DATE <br />ass. <br />NAME OF TANK ER/AGENT (print) 485• TITLE OF TANK OWNER/AGENT 486. <br />UPCF (1/99) H*wrc-c -1/2 http://www.unidocs.org Rev. 02/16/00 <br />