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UNIFIED PROGRAM CONSOLIDATED FORM �J <br /> U <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATI§V� 3 '2008 <br /> ECERTIFICATE OF COMPLIANCE <br /> G `J R C���''�fl i`'(0;-e"�44er tank) <br /> ti 11; ,C `Page J of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILrfY NAME or DBA—Doing Business As) 3. <br /> Z— <br /> ADDRESS(For local use only) 476. <br /> FACILITY ID11 1• TANK ID# 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 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 483. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> C-"\ <br /> M.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE O ANK OWNER/AGE DATE sea. <br /> \C) <br /> NAME 0 0MRAGENT(print) ` 483 TITLE OF TANK OWNERAGENT 4e6. <br /> �C-0 � A 1 C - <br /> UPCF(1/99)Hwfwrc-c-1/2 http://www.unidoes.org Rev.02/16/00 <br />