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FIED PROGRAM CONSOLIDATED FOO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page 1 of 2 <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Chevron Station#94275 <br /> ADDRESS(For local use only) <br /> 476 <br /> 2905 W. Ben'amin Holt, Stockton,CA 95207 <br /> FACILITY ID# 1 TANK ID# 477 <br /> 0 0 0 0 0 0 0 0 0 0 0 <br /> 1 Regular Unleaded UL#A73746 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478 <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 479 <br /> with underground storage tank installations. <br /> 480 <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 482 <br /> 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 applicable 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> NEW 30,000 Gal TANK& LINE INSTALL DATE 6/17/05 <br /> III. TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true ccura to the st of my knowledge. <br /> GNATURE OF TANK OWNER/AGENT DATE 484 <br /> ny Qtd�aCvo 1011105 <br /> NAME OF TANK OWNER/AGENT(print 485 TITLE OF TANK OWNER/AGENT 486 <br /> Chevron Products Company/Tony Quij o CHEVRON/Project Manager, Staubach Company <br /> UPCF(1/99 revised) 177 Formerly SWRCB Form C <br />