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UNIFIED PROGRAM CONSOLIDATED FORM 1 <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS ` <br /> UNDERGROUND STORAGE TANKS -INSTALLATION I <br /> I <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page _ of _ <br /> 1.FACILITY IDENTIFICATIM <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing SUsiness As) <br /> ®L)(C- <br /> ADDRESS(For/acal use only) <br /> S7zNCtK 74-11-/ C4. 5.S' <br /> FACILITY ID# <br /> 37 <br /> 11. INSTALLATION <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> ;--11"�The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> e 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 /> �/The <br /> he installer has been certified or licensed by the Contractors'State License Board. <br /> 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 ceraty em the information provided herein is true and acarrate to Me best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE <br /> A S- " G-d <br /> NAME OF TANK OWNER/AGENT 011010 TITLE OF TANK OWNERIAGENT <br /> S U/lH w)ND+�1Q j I✓C'i �� C� �NI�� <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br />