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NIFIED PROGRAM CONSOLIDATED FORM <br /> SAN JOAQUIN COUNTY UNIFIED PROGRAM - TANKS <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page Z of <br /> L.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> p <br /> ADDRESS(Forlocal use only) <br /> 6 00 I G Obl�-7vt l 1 <br /> FACILITY ID# 1 TANK ID# <br /> II. INSTALLATION <br /> (Check all that apply) <br /> \�I The installer has been trained and certified by the tank and piping manufacturers. <br /> )I The installation has been inspected and certified by a registered professional engineer having education and <br /> experience with underground storage tank installations. <br /> 1`0 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 /> \1I The installer has been certified or licensed by the Contractors' State License Board. <br /> `2 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 OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK WNER/AGENT DATE <br /> NAME OF TANK OWNER/AGENT(pdnq TITLE OF TANK OW(NERIAGENT <br /> CUPAFORMS(4/99) • Formerly SWRCB Form C <br />