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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One page per tank) <br /> Page_of� <br /> 1. FACILITY IDENTIFICATION <br /> 3. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) <br /> Rancho San Mi vel Market <br /> 476. <br /> ADDRESS(For local use only) <br /> 1409 Air ort Wa Stockton, CA 95205 477 <br /> FACILITY IDk <br /> TANK ID M <br /> 2 10,000 91 Octane <br /> 11.INSTALLATION <br /> (Check all that apply) <br /> 478, <br /> ® The installer has been trained and certified by the tank and piping manufacturers. <br /> ❑ <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 /> 480. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 491. <br /> n All work listed on the manufacturer's installation checklist has been completed. <br /> W. <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 493, <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> Installation of Petro-First underground fueling system that has a two compartment <br /> storage system 20,000110,000 <br /> 111.TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information vided re' is true and accur to to the best of my knowledge. <br /> S[GNATU OF T NT DATE 4a4. <br /> x/17/03 <br /> NAME OF TANK OWNERIAGENT(print) 495. TITLE OF TANK OWNERIAGENT axe. <br /> Bob J. Hill Contractor <br /> UPCF(I/99)I1wfwrc-c-1l2 http:/Iw"w.tiniducs.org Rev.02/16140 <br />