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Sep 16 08 09:41a Reliable Petroleum <br />209-845-8953 p.2 <br />0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TS -- INSTALLATION <br />CERTIFICATE OF CODT.PLIANCE (—e page per zap) <br />Page _ of _ <br />L FACILITY IDENTEMATION <br />3 <br />BUSINESS NAME (Same asFACILITY NA1 erR A—DomgHusinm&As, <br />ADDRESS(Yor meal use wily) aT6 <br />�� � � mos x.0,1 -e c. ��op ., F3,c) <br />TMFACILITY IDN I , TANK�^II N an <br />II. INSTALLATION <br />(Check all that apply) <br />.na <br />❑ 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 ;'O <br />with underground storage tank installations. <br />ago <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 />a82 <br />The installer has been certified or licensed by the Contractors' State License Board_ <br />ask <br />❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />voluntary consensus standards and written manufacturer's installation procedures. <br />Description of work being certified: f ,/(fe Qua,- en—jso) le, <br />?_e,Cro-Lcd u- i ^f �l <br />Y, <br />DV r %, -P afu c� � � 2��n , <br />RT S , <br />�2'C.J%.� L �,2--C� d- � �-- � �GY li'Z.Ct•. `? C` e �S � }' <br />HL TANK OWNER/AGENT SIGNATURE <br />HL <br />1 ccrt at the information prov' ed herein is true and accurate to the best of my knowledge. <br />�'iCs. OF TA �AGENT�. <br />4114 DATE/ <br />ag b <br />N NK ZO T OWNS A 465 <br />TrrL F T K O EWAGENT <br />UPCF (1,199 revised) 14 Formerly SWRCB Form C <br />