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UNIFIPLD PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS—INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per milt) <br /> 1. FACILITY IDENTIFICATION <br /> BUSIN ----------- <br /> ` ._...._ ._. ._ <br /> :SS NAMEO "�.r earn•NAME of onA-not,,na4fm Au a <br /> SHELL 011,CO. <br /> ADDRESS(rart«ai we ml:9 .___ - 476 . <br /> 3515 NAV Y I)RIVE STOCK'I'ON,CA 95203 <br /> FACILITY IM 'I TANKIDB -- JS] <br /> WASTE TANK <br /> II.INSTALLATION <br /> (Cheek all that apply) -- <br /> The installer has been(tamed and certified by the funk and piping manufacturers. ib <br /> The installation has been inspected and certified by a registered professional engineer having education and experience Jr' <br /> Ivith underground storage lank installations. <br /> ® The installation has beeninspected and approved by the Unified Program Agency. no <br /> ® All work listed oil the manufacturer's installation checklist has been completed. 61 <br /> ® <br /> The installer has been certified or licensed by the Contractors' State License Board. et <br /> ® The underground storage tank,any primary piping,and secondary containment was installed according to applicabic 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> Installed(2) 1 Isg.gx6.W.M Icon Piping Penetration Pittings,Sump 2 <br /> Installed(1)3.5x].6 Icon Electrical Piping Penetration Fittings,Sunup 2 <br /> Installed(1)6.8x4.5A Icon Split Penetration,Sunup 1 <br /> Secondary Containment Testing Passed 12/11/2012 <br /> III. TANKOWNER/AGENTSIGNATURE <br /> I certify that the infatinalion provided herein is true and accurate to the best of toy knowledge. <br /> SIGNA'fUQF�TANK VNBN ! <br /> + 3 <br /> 6a <br /> NAME4P OINERAGE '(pni9 7fL0 _A :OrNNI2/AENT <br /> UPOP(1/99 revised) 14 Formerly SIYRCE Form C <br />