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UNIFIED PROGRAM CONSOLIDATED FoKm <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 /> BUSINESS NAME(Same as FACIUTY NAME or DBA-Doing Busvms As) <br /> U►W, c SST <br /> ADDRESS(For local use only) <br /> FACILITY ID# 1 TANK ID# — <br /> M <br /> 100, <br /> II.INSTALLATION <br /> (Check all that apply) <br /> The installer has been trained and certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 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 /> 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 /> III.TANK OWNER/AGENT SIGNATURE <br /> I carbfy that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGENT DATE <br /> NAME OF TANK OWNER/AGENT(pont) TITLE OF TANK OWNER/AGENT <br /> 91Z <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br />