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U ED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Peg-2 of 2 <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(game as FACILITY NAME or DBA—Wing Business As) 8 <br /> Chevron Station#210997 <br /> ADDRESS(For tical use only) 476 <br /> 1442 A Colony Drive, Ri on 95366 <br /> FACILITY ID# I TANK ID# 477 <br /> 0 0 0 0 0 0 0 0 0 0 0 2 Supreme Unleaded <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 4]8 <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 /> 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 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> NEW STATION CONSTRUCTION INSTALL 1/16/2003 <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information p7 d ' true ac urate to the best of my knowledge. <br /> SIGNATURE OF TANK T DATE 480 <br /> Geoff Vogel/M April 24,2003 <br /> NAME OF TANK O WNE p' t) 485 TITLE OF TANK OWNER/AGENT 486 <br /> Chevron Products Com eoff V el Project Engineer <br /> UPCF(1/99 revised) 178 Formerly SWRCB Form C <br />