Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE one page per tank) <br /> F'u6e�of I <br /> 1.FACILITY IDENTIFICATION <br /> BUSINGSSNAME(sangasFAClt.rrYNAMI o,DI)A Doimgnusin As) 3 <br /> E.F. KLUDT&SONS,. INC. <br /> ADDRESS trot 1a of�.oalvt 47d <br /> 1126 E.PINE ST., LODI CA 95240 <br /> FACILITY IDN t TANK ID tt 477 <br /> Tank No. 7-UG <br /> II.INSTALLATION <br /> (Cheek all that apply) <br /> ® The installer has been trained and certified by the tank and piping manufacturers. 476 <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 /> 464 <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> aei <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> aHz <br /> X 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 4£93 <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 /> III. "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/AGFNT DATE 484 <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNEPIAGENT 486 <br /> STEPHEN KLUDT PRESIDENT <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />