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1%W NNW <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page 2 of 2 <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(same u FACMIt NA or DBA-Doing By:Nee.AS) 3. <br /> Tracy Chevron <br /> ADDRESS(Eo<ioei um only) 476 <br /> 3400 McArthur Boulevard,Tracy,CA <br /> FACILITY IDI t TANK IDN 4]]_ <br /> 2— 20,000-gallon Split Tank (91/Diesel) <br /> IL INSTALLATION <br /> (Check all that apply) <br /> °ye. <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 619- <br /> with underground storage tank installations. <br /> °so. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> at <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 4sz. <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 °83. <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 /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU3}E OF TANK OWNER/AGENT DATE <br /> r" 02/05/03 <br /> NAME OF TANK OWNER/A ENT(print) TITLE OF TANK OWNER/AGENT 486_ <br /> Autumn Blakley- 485 <br /> Balch Petroleum Contractors&Builders,Inc Contractor <br /> UPCF(1/99)Hwfwrc-c-2/2 h@p://www.unidoc&org Rev.02/16100 <br />