Laserfiche WebLink
NIFIED PROGRAM CONSOLIDATED FO M <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM -TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page j— of 3 <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> i <br /> ADDRESS <br /> ,,(For local use only) ® J� <br /> FACILITY ID# 1. 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 /> The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> SLI 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 /> t 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 <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br /> work being certified: <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> I ca tify that the information provided herein is true and acaaate to the best of my knowledge. <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 />