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UNIFIED PROGRAM CONSOLIDATED FORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION I <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page _ of _ <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) <br /> ADDRESS(For local use onW <br /> 01 v_sP 7 S. L°�rrxr4 v S c>G <br /> FACILITY ID# a ., 1 TANK 10# <br /> II. INSTALLATION <br /> (Check all that apply) <br /> (g' The installer has been trained and certified by the tank and piping manufacturers. <br /> 2r The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> d/ The installation has been inspected and approved by the Unified Program Agency. <br /> o All work listed on the manufacturer's installation checklist has been completed. <br /> p' a 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 /> I <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and acc sme to the hest of my knowledge. <br /> SIGNATURE OF TANK OWNER/ ENT DATE <br /> NAME OF TANK OWNER/AGENT(pnno TITLE OF TANK OWNER/AGENT <br /> SU){ A1C0� S 11v-C:H d ltiN <br /> CUPAFORMS(4/99) Fortnerly SWRCB Form C <br />