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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page tank) <br /> Page_of <br /> L FACILITY IDENTIRCATION <br /> BUSINESS NAME(S66aan''e as FACXrFY NAME or ABA—Doing Aa) 3. <br /> V <br /> ADDRESS(For focal use Defy) <br /> 476. <br /> 12,lb 6 �k C_�_YLCJ <br /> FACILITY IDI TTJ I I I. I TANK ID{i 477. <br /> II. ST TION . <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 /> 480. <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 /> 482. <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 /> Description of work being certified: <br /> T K OWN AOEI"�T S1Gll�lA <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN F T ENT DATE <br /> 484. <br /> NAW OF TANK OWNER/AGENT(print) 77—h -14ye <br /> �S s TITLE OF TANK OWNER/AGENT 486• <br /> ec,C !fy i v ,,,, <br /> UPCF(1/99)H -1/2 hope/ ®rg Rev.OV16100 <br />