Laserfiche WebLink
TrNIFIED PROGRAM CONSOLIDATED FORfi <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page _ Of <br /> I.FACILITY IDENTIFICATION <br /> SUSINES NAME(Same as FACILITY NAME or OBA-Ody BuaMsaa As) <br /> U<- <br /> AODRESS(For kcal use omY) / <br /> FACILITYIDS t I TANKIO% <br /> II. INSTALLATION <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> L9 The installation has been inspected and certified by a registered professional engineer having education and <br /> / experience with underground storage tank installations. <br /> Q The installation has been inspected and approved by the Unified Program Agency. <br /> All work listed on the manufacturers installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> IY The underground storage tank, any primary piping, and secondary containment was installed according to <br /> applicable voluntary consensus standards and written manufacturer's installation procedures. Description of <br /> work being certified: <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> i mNy Mar Me intamabon provided harem is We aM amrsts m MO Deal a1 my km a4P. <br /> SIGNATURE OF TANK OWNEWAGENT DATE <br /> 1 Dov- �3 /99 <br /> NAME OF TANK OWNEWAGENT(pMp TITLE OF TANK OWNER/AGENT <br /> �- dlnK �L r f v or <br /> CUPAFORMS(4/99) Fomleny SWRCS Form C <br />