Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page 1 of 2 <br /> L FACILITY IDENTIFICATION D <br /> BUSINESS NAME(Same w FAMM NAME or DBA-Doing Business Aa) 3, <br /> Tracy Chevron MAR 2 4 2004 <br /> 476. <br /> ADDRESS(F« iume iy) ENVIRONMENT HEALTH <br /> 3400 McArthur Boulevard,Tracy,CA <br /> FACILITY IDM TANK IDN 4n. <br /> 1- 20,000- lon UST 87 Regular Unleaded <br /> 11 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 4' <br /> with underground storage tank installations. <br /> 480 <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 48) <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 483. <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> Installation of new USTs and associated piping. <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is nue and accurate to the best of my knowledge. <br /> S ,IATURE-0ETANK OWNER/AGENT, DATE 484. <br /> C<.CC l_ {C // �� . 02/05/03 <br /> NAME OF TANK O WNER/AG"(print) TITLE OF TANK OWNER/AGENT 486. <br /> Autumn Blakley- 485. <br /> Contractor <br /> Balch Petroleum Contractors&Builders,Inc <br /> UPCF(1/99)Nwfwre�-1/2 hup://www.unidoes.org Rev.02/16/00 <br />