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NIFIEO PROGRAM CONSOLIDATED FORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM -TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page _ of <br /> L,FACILITY IDE NTIFICAtION <br /> W BUSINESS NAME(Same as FACILITY NAME or DBA-Oo, g Business As) <br /> I <br /> ADDRESS(ForMcal use only) /� ``�� <br /> 490' <br /> �c- <br /> FAC[UTYID# 1 TANK <br /> IL INSTALLATION <br /> (Check aU 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 /> 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 /> 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 /> III:TANK OWNERIAGENT SIGNATURE', <br /> th a in aeon ad herein is Gus to the best of my knowledge. <br /> N DATE <br /> NAME OF TANK 0AGENT(print) "w TITLE TANK UAGENT <br /> N c <br /> CUPAFORMS(4/99) Formerly SWRC13 Form C <br />