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UNIFIED PROGRAM CONSOLIDATED F0141 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page 1 of 2 <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same.FACMTY NAME or DBA—Doing Busincas N) 3 <br /> Chevron Station#210997 <br /> ADDRESS(For 1ocal..1y) 476 <br /> Hwy 99&Colony Drive,Ripon CA 95366 <br /> FACILITY ID# TANK ID# <n <br /> 0 0 0 0 0 �% 0 0 0 0 0 0 1 Regular Unleaded <br /> II.INSTALLATION <br /> (Check all that apply) <br /> ® The installer has been trained and certified by the tank and piping manufacturers. 479 <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 /> ® The installation has been inspected and approved by the Unified Program Agency. 480 <br /> ® <br /> All work listed on the manufacturer's installation checklist has been completed. 481 <br /> ® The installer has been certified or licensed by the Contractors' State License Board. 482 <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 TARGET INSTALL 7/1/02 <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE 494 <br /> D.R.LERI 4/16/02 <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNEWAGENT 486 <br /> Chevron Products Company/Geoff Vogel Project Engineer <br /> UPCF(1/99 revised) 177 Formerly SWRCB Form C <br />