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0 A <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATIONCERTIFICATE OF COMPLIANCE (011C page�f'�'kk <br /> Pu�u 7 of� <br /> 1.FACILITY IDENTIFICATION <br /> T <br /> FBUSrNAME(S_ixs rAc[LtTI'NAME v:MA hang}Ins—o As) <br /> DT& SONS, INC. ala <br /> 1w 1 use nn[y) <br /> 4126 E.PINE ST., LODI CA 95240 aaz <br /> FACILITY lDfl I TANK ID# <br /> Tank No. 8-UG <br /> II.INSTALLATION <br /> {Check all that apply) <br /> 47N <br /> [F1 <br /> Tine installer has been trained and certified by the tank and piping manufacturers. <br /> 47) <br /> The installation has been inspected and certified by a registered professional engineer having education and experience <br /> with underground storage tank installations. 490The installation has been inspected and approved by the Unified Program Agency. <br /> aet <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> asz <br /> X The installer has been certified or licensed by the Contractors' State License Board. <br /> 483 <br /> K The underground storage tank,any primary piping,and secondary containment was installed according to applicable <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 NEIN UNDER-DISPENSER CONTAINMENT&MONITORING SYSTEM. <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the inf=lation provided herein is true and accurate to the best of my knowledge. <br /> APA <br /> SIGNA T O ER/ 'NT pATnP- <br /> NAME OF TANK OWNER/AGENT(print) 495 TITLE 4F TANK,OWNER/AGENT <br /> STEPHEN KLUDT PRESIDENT <br /> UPCF(].199 revised) 14 Formerly SWRCB Form C <br />