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UNIFIED PROGRAM CONSOLIDATED I- ORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS f <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) I <br /> -age _ of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> 0 8U ' fl vs <br /> ADDRESS(For local use only) <br /> SS,e a(4,0 rte? <br /> FACILITY ID# 7 TANK ID# <br /> II. INSTALLATION <br /> ("Check all;hat apply) <br /> Com/ The installer has been trained and certified by the tank and piping manufacturers. <br /> p 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 /> ❑V✓ All work listed on the manufacturers installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> Q' 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 certify that the intonnaticn orowded herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE <br /> ,NAME OF TANK OWNER/AGENT(print) TITLE OF TANK OWNER/AGENT <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br />