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UNIFIED PROGRAM CONSOLIDATED FORM <br />SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />(one page per tank) <br />Pw. 2 w a <br />I. FACILITY IDENTIFICATION: <br />BUSINESS NAME IBM@ as FACIU1 NAME m OBA- Gobq BuMMa. Aa) � <br />4ftw lknlloljq F4,tF 11-43-f <br />ADDRESS (Form .Dray) <br />�o r w &MAW Z-0,0/ C- 4 '?5-240 <br />FACILITY ION t iANN IpY <br />3 13 4 1 S t So 0 y- - dot Dom unrzea v0 <br />It. INSTALLATION <br />(Check all that apply) <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 <br />experience with underground storage tank installations. <br />CR*� 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 />lzr� The installer has been certified or licensed by the Contractors' State License Board. <br />Er The underground storage tank, any primary piping, and secondary containment was installed according to <br />applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br />work being certified: <br />III. TANK OWNERIAGENT SIGNATURE <br />I oKBIY mal tln Inmm�.tlon FleadM Naval is bv..M mole m ma ball of mY mmwwq.. <br />SIGNATURE OF TANK ON ER/AGENT <br />"1 - bvn7.0 L�� <br />GATE <br />7/3o1`t9 <br />NAME OF TANK ON ER/AGENT Op ) <br />TITLE OF TANK I ENAGENT <br />�'Ma,�2�'mn1 C'a�STrevl.TcgsL7 <br />�S�/'�2in/Y�n/o6,v� <br />CUPAFORMS (4/99) <br />Formedy SWRCa Fonn r'. <br />