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Oct 05 04 08:17a Fr=-zen Hill 559rg81467 p.2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (onc page per lai <br />r:�,• <br />1 Irl <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sante ns FACILITY NAME. or DBA — Doing Business As) <br />' <br />Gas 4 Less <br />_ <br />ADDRESS (For local oso only) <br />476 <br />3408 Manthey Road Stockton, CA <br />FACILITY [DH <br />I <br />TANK ID # <br />477F <br />A <br />0 <br />0 <br />1 <br />�314 <br />8 <br />4 <br />I1. INSTALLATION <br />(Check all that apply) <br />479 <br />❑x 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 <br />4'9 <br />with underground storage tank installations. <br />430 <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 />4K <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 <br />493 <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: <br />Installation of fuel island extension with (1) 24' x-:26' Cahopy Extension <br />(1) Wayne Dispener, with Healy Assist Vapor Recovery Phase 11, Hose and Nozzle <br />Environ 48" dispenser pan with Stainless steel flex, safety valve and brackets <br />(1) VeederRoot Liquid Sensor <br />111. TANK OWNER/AGENT SIGNATURE <br />1 certify that the information provided herein is true and accurate to the best of my knowledge. <br />ONER/AGENT <br />SIGNATUR pNKW <br />�' / <br />DATE <br />^84 <br />i , <br />1 <br />NAME O 'TANK OWNER/AGENT (print) 485 <br />TITLE OF TANK OWNER/AGENT <br />4g� <br />Franzen -Hill Corp. Agent <br />Job Foreman -Agent <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />