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�a�i fIED PROGRAM CONSOLIDATED FOTANKS <br /> UNDERGROUND STORAGE TANKS- INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (m a pane Per tack) <br /> Page_d_ <br /> L FACILITY IDENTIFICATION <br /> 3 <br /> BUS INESSNA IE(S eu FACH] NAMEmDDA-Doing Businms Ae) <br /> Safeway Store#1769 476 <br /> ADDRESS(Pm JocW—uoly) <br /> 2808 Country Club Boulevard,Stockton,CA 417 <br /> FACILITY J t TANK IDR -7 <br /> 1769-1 <br /> IL INSTALLATION <br /> (Check all that apply) <br /> ns <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 /> Oga <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> Oat <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 4g3 <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 /> 11.1<3rA�L�c�oIS of A 'lotooO (gs'cLWt�1 SIIJC-�\-E. <br /> Lol�IPI��T�lE1sT UgSr. <br /> M. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and acc iratc to the best of my knowledge. <br /> GN A OFT K GENT DATE Ot° <br /> AJN TANK ENT(taint) ens TrrLEOF WNER/AGENT esti <br /> DA-Agent Project Manager <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />