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""`u NIFIED PROGRAM CONSOLIDATED FOVIM <br />SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME Isms as FACIUTY NAME or DBA - Doirq Bwlnesa As) <br />(one page per tank) <br />P'. 3 or 3 <br />of w. XJzE/YIIsYN G.Al L�Ol � li1% g524a <br />FAOILITY IOA1 TANK IDM <br />.a 2 3 1 3 I Aj(i <br />II. INSTALLATION <br />(Check all that apply) <br />Z( 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 />fX 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 />0 The installer has been certified or licensed by the Contractors' State License Board. <br />fil 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 OWNER/AGENT SIGNATURE - <br />I Fenny MM Ma MIMasedw provided tsMse is Me are soarale M Me bem of my b,mvlad"a <br />SIGNATURE OF TANK OWNER/AGENT <br />DATE <br />NAME OF TANK OWNER/AGENT(pnm) <br />#kAvDCRSoA) dVAJ,SrP-VCr6Cnl <br />TITLE OF TANK OW ER/AGENT <br />suA��2rlti1 ND�rr� <br />CUPAFORMS (4/99) Formerly SWRCB Form C <br />