Laserfiche WebLink
l?-W IED PROGRAM CONSOLIDATED FORIW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE °a`pam per tank) <br /> Peae—of <br /> 1. FACILITY IDENTIFICATION <br /> 3 <br /> BUSINESS NAME(s.mo v Fwcatn rvwam o<otu-oo�q nv.me..w9) <br /> Safeway Store#1769 476 <br /> ADDRESS(For bui o-Dory) <br /> 2808 Counq Club Boulevard, Stockton,CA <br /> FACILITY ID# t TANKID# ,G an <br /> 1769-2 <br /> 11. INSTALLATION <br /> (Check all that apply) <br /> 471 <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 4T <br /> with underground storage tank installations. <br /> aao <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> �t <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> aes <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 °&S <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> r-1 of A.tJ vST; v�AL <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the hest of my knowledge. <br /> NAT FT K GENT DATE a80 <br /> NA '" AN GFNT(print) 985 TITLE T OWNER/AGENT <br /> J EDA-Agent I Project Manager <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />