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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE.OF COMPLIANCE+. sone page per Lwk) <br /> -- - page_of_ <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same asFAC11.FfYNAMEorDBA Dotngliume,.9M) 3 <br /> E.F. KLUDT&SONS, INC. <br /> ADDRESS(For local use only 476 <br /> 1126 E. PINE ST., LODI CA 95210 <br /> FACILITY IDft I TANK ID# 477 <br /> Tank No. 6-UG <br /> It.INSTALLATION <br /> (Check all that apply) <br /> 478 <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 /> 480 <br /> ] The installation has been inspected and approved by the Unified Program Agency. <br /> 4al <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 /> INSTALL NEW TANK TRIM AND UNDERGROUND PIPING. <br /> INSTALL NEW UNDER-DISPENSER CONTAINMENT& MONITORING SYSTEM. <br /> 111. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE 484 <br /> NAME OF TANK OWNERIAGENT(print) 485 TITLE OF TANK OWNEWAGENT 4116 <br /> STEPHEN KLUDT PRESIDENT <br /> UPCF(1/99 revised) 14 Fonnerly SWRCB Form C <br />