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UNIFIED PROGRAM CONSOLIDA'T'ED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - ]INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per irk) <br /> Page or .( <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same ac FACILITY NAME or DHA- Doing H—wss At) 3 <br /> E.F. KLUDT& SONS, INC. <br /> ADDRESS(Foe lata)use oo4y) 476 <br /> 1126 E. PINE ST., LODI GA 95240 <br /> FACILITY[Dt! ) TANK ID# 477 <br /> Tank No. 8-UG <br /> IT.INSTALLATION <br /> (Cheek all that apply) <br /> 47A <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 /> aea <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> All work listed on the manufacturer's installation checklist has been completed. 4NI <br /> ® The installer has been certified or licensed by the Contractors' State License Board. 462 <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 /> III. TANK OWNER/AGENT SIGNATURE <br /> 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE.OF TANK OWNER/AGENT DATE 4F4 <br /> NAME OF TANK OWNER/AGENT(print) 965 TITLE OF TANK OWNER/AGENT 49 <br /> STEPHEN KLUDT PRESIDENT <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />