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'O NIFIED PROGRAM CONSOLIDATED FWM <br />SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />'I (one page per tank) <br />FNa of 3 <br />I. FACILITY IDENTIFICATION: <br />BUSINESS NAME (Same as FACILITY NAME a OBA -Dollq SN sss Ar) <br />QR 60 4olIPM r—A(2 * 93 <br />ADDRESS (Po hxal. o*) <br />501 W, Z/J Z-0-0/, C/i, K524o <br />FACIU Y 10 a1 TANK 101 1 #111 <br />2 3 1 3 4 1 s -I 55 b l l to moo U�✓� M D <br />II. INSTALLATION <br />(Check all that apply) <br />d 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 />The installation has been inspected and approved by the Unified Program Agency. <br />Gds/ All work listed on the manufacturers installation checklist has been completed. <br />C/ The <br />The installer has been certified or licensed by the Contractors' State License Board. <br />Cl?/ The underground storage tank, any primary piping, and secondary containment was installed according to <br />applicable voluntary consensus standards and written manufacturers installation procedures. Description of <br />work being certified: <br />III. TANK OWNER/AGENT SIGNATURE <br />I,ar*Bad Its ks"Ifii w odW&Wi Is ma aal efa„aM b tla Ge of my Fmw"e. <br />SIGNATURE OF TANK OW EWAGENT <br />OWTE <br />NAME OF TANK OWNEWAGENT (pm O <br />1416 WDE/2S'Ql/tl @�sr�,uc� ea��Il <br />TITLE OF TANK OYMENAGENT <br />� LlNF2cn lrF fd nlr <br />CUPAFORMS (4/99) <br />FomlMy SWRCB Form C <br />