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UNIFIED PROGRAM CONSOLIDATED rORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> ?age _ of _ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> tiz- <br /> ADDRE S(For Notal use only) <br /> S-(FC / 7 <br /> `J DU � !E C}�Lk <br /> FACILITY ID# t TANK ID# <br /> II. INSTALLATION <br /> (Check all that apply) <br /> / The installer has been trained and certified by the tank and piping manufacturers. <br /> a 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 /> All work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> 4�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 information provided herein is true and accurate to the test of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE <br /> NAME OF TANK OWNERIAGENT(pent) TITLE OF TANK OWNER/AGENT <br /> i <br /> CLIPAFORMS(4/99) Formerly SWRCB Form C <br />