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rl <br />a <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - INSTALLATION <br />CERTIFICATE OF COMPLIANCE (one page per tank) <br />Pogc � of —1 <br />1. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same a, FACILITY NAME or DBA - Doing Business Ac) <br />3 <br />FLAG CITY CHEVRON <br />ADDRESS (For local use on)y) <br />476 <br />6421 CAPITOL AVE., LODI, CA 95242 <br />FACILITY IDfI <br />TANK ID ft <br />477 <br />HTankNo.3 <br />II. INSTALLATION <br />(Check all that apply) <br />® The installer has been trained and certified by the tank and piping manufacturers. <br />478 <br />❑ The installation has been inspected and certified by a registered professional engineer having education and experience <br />479 <br />with underground storage tank installations. <br />® The installation has been inspected and approved by the Unified Program Agency. <br />460 <br />® All work listed on the manufacturer's installation checklist has been completed. <br />48] <br />® The installer has been certified or licensed by the Contractors' State License Board. <br />asz <br />® The underground storage tank, any primary piping, and secondary containment was installed according to applicable <br />abs <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. <br />M. TANK OWNER/AGENT SIGNATURE <br />I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNAT <br />489T <br />dA -.V"" : r S <br />NAME OF TANK OWNER/AGENT (print) 495 <br />TITLE OF TANK OWNER/AGENT <br />486 <br />KAREN DHINGSA <br />FACILITY MANAGER <br />UPCF (1/99 revised) 14 Formerly SWRCB Form C <br />