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FIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page I_of 4 <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Loves Country Sores of California <br /> ADDRESS(For local use only) 476 <br /> 1510 Jack Tone Road, Ripon,CA 95366 <br /> FACILITY ID# l TANK ID#UL#M837433 477 <br /> Double-wall Jacketed Glasteel II, <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 /> F_� 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 /> Installed 4 Glassteel fuel tanks with fiberglass dispenser containment boxes. Installed"Smith Red Tread II"double wall fiberglass <br /> Product piping. Installed a Veeder-Root TLS-350 Monitoring system,all tanks and dispenser sumps are monitored. <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify th the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN OF TAN O AGENT DATE 484 <br /> June 27,2001 <br /> NAME OFT WNER/AG (print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> Craig Bell Project Manager,Fillner Construction, Inc. <br /> UPCF(1/99 revised) 177 Formerly SWRCB Form C <br />