Laserfiche WebLink
UwrFIED PROGRAM CONSOLIDATED FOkW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_o <br /> I. FACILITY IDENTIFICATION <br /> 3 <br /> BUSINESS NAME(Sameser FACILnv NAME or DBA-Doingeukne Aa) <br /> Safeway Store 41769 <br /> 4]6 <br /> ADDRESS(Por fool use ony) <br /> 2808 Country Club Boulevard, Stockton,CA <br /> FACILITY IDk 1 TANKIDU an <br /> 1769-2 <br /> 11. INSTALLATION <br /> (Check all that apply) <br /> 4]e <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 47' <br /> with underground storage tank installations. <br /> 980 <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 /> ►1J2Tqu-A-tto►J of AIJ usT •� ��A�-- C.oMPAQ.�T'- <br /> -�T TAc►-�1L- <br /> III. TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> GNATU OF'TANLK OWNLWAIIENT DATE �+ <br /> N K NT(print) ergs TITLE OF ANK WNER/AGENT <br /> J EDA-Agent Project Manager <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />