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UNIFIED PROGRAM CONSOLIDATED FORM ! <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> I <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(SM as FACIUW NAME P,OBA-Oavig Bumm Aa) <br /> 3a tA gni/ <br /> AOOP.ESS(Fgrlocaf uv oNyf / <br /> J t <br /> fACNTY IGY1 ANKIOY <br /> ^s <br /> II. INSTALLATION <br /> / (Check all that apply) <br /> 6� The installer has been trained and certified by the tank and piping manufacturers. <br /> G� The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> +0'/ The installation has been inspected and approved by the Unified Program Agency. ! <br /> gyp/ All work listed on the manufacturer's installation checklist has been completed. <br /> The installer has been certified or licensed by the Contractors' State License Board. <br /> by The underground storage tank,any primary piping, and secondary containment was installed according to <br /> applicable voluntary consensus standards and written manufacturers installation procedures. Description of <br /> work being certified: <br /> it <br /> II <br /> 111.TANK OWNERIAGENT SIGNATURE <br /> I <br /> I oNuh INM tM YIIdmYYgn arariBaO twain is OeY a„0 amaalY m g1Y Mal W my MnavAaUT. i <br /> SKaNATURE OF TANK O EWAGENT DATE <br /> Ala <br /> NAME OF TANK OWNERIAGENT(PnnV TITLE OF TANK OA MAGENT <br /> Jo /4 do O <br /> AV <br /> CUPAFORMS(4199) Formerly SWRC8 Form C <br />