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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> TANKSUNI)ERGROUND STORAGE -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page T of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(gam w FACUMT NAME DBA-notes Husmss As) 3•., <br /> ADDRESS(For local use only) a <br /> 476. <br /> e?-Z)(a 0 - �g L <br /> FACILITY IM 1• TANK ID# 477• <br /> II.IlVSTA <br /> LIA ,ION <br /> (Check all that apply) <br /> 479. <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 a7v. <br /> with underground storage tank installations. <br /> 490. <br /> ❑ The installation has been inspected and approved by the Unified Program Agency. <br /> 491. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> 492. <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 /> "I'ANK <br /> O A T SIGNA <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN OFT �OWNER/AGENT DATE 484. <br /> f <br /> NAME OF TANK OWNER/ G t) • TITLE OF TANK O <br /> LJPCF(1/99)H -1/2 ht1p:/twww.vn1docsorg Rev.02flfiM <br />