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UNIFIED PROGRAM CONSOLIDATED FORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page _ of _ <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or 0eA-o7u mess As) <br /> 4",, <br /> c v v <br /> ADDRESS(Forlocal use only) <br /> FACILITY ID>r TANK 10 N <br /> Il. INSTALLATION <br /> (Check all that apply) <br /> t!f" 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 /> of The installation has been inspected and approved by the Unified Program Agency. <br /> C11" All work listed on the manufacturer's installation checklist has been completed. <br /> U The installer has been certified or licensed by the Contractors' State License Board. <br /> 17 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 /> Ill.TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is hue and accurate to the best of my knovAedge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE <br /> NAME OF TANK OWNER/AGENT(pnnt) TITLE OF TANK OWNER/AGENT <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br />