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02/05/2004 15:31 40894201?' BALCH PAGE 02 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> lone page per u <br /> Page i <br /> 1 <br /> L FACILITY IDENTIII'ICATION <br /> BUSINESS NAME iu�r..rncn.rrr Nnrnye.uan um.a uu,aw,n.t I <br /> TrAcy Chevron <br /> ADDRESS mm kK,or o.bl <br /> 3400 McArtbur Boulevard,Tracy,CA <br /> FACILI 1 IDM TANK IUM <br /> 2— 20, on Split Tank 91/Dietld <br /> J <br /> IL INSTALLATION <br /> (Check all that apply) 1 <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 <br /> with underground storage tank installations. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> ® All work listed on the manufacturer's installation checklist has been completed. <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 /> I <br /> Installation of nese USTs and associated piping. <br /> DI.TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided heroin is true and aeournc t0 the best of my knowledge. <br /> SIGNAT E OF F AN K O WN ER/AGENT DATk e. <br /> �- �:^ �'rp �• 02/05/03 fl <br /> NAME OF TANK WNER/A ENT(print) 'rITLE OF TANK OWNEK/AUENT 'I <br /> Autumn Blakley- 05. <br /> Balch Petroleum Contractors&Builders,Inc. Contractor <br /> UMF(1199)Hwfwre-c-241 bttp://www.unidoea.org Rev.02/16/00 <br />