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NIFIED PROGRAM CONSOLIDATED FOR <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 /> 1.FACILITY IDENTIFICATION,-- <br /> BUSINESS <br /> DENTIFICATION,-BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> EACOi-� <br /> ADDRESS(For•loca/use o*) '�^^�� a g� <br /> I®C_3 ' V5 ` I 1 Cillv <br /> — <br /> FACIUTY'ID# u 1 TANK 10# <br /> l <br /> 11.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 /> 12 The installation has been inspected and approved by the Unified Program Agency. <br /> 2 All work listed on the manufacturer's installation checklist has been completed. <br /> 10 The installer has been certified or licensed by the Contractors' State License Board. <br /> 19 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 /> X, 111 TANK OWNERIAGENT SIGNATURE <br /> I certify that the information provided herein is hue and acoutate to the best of my knowledge. <br /> SIGNATURE OF TANI OWNER/AGENT DATE <br /> l0 <br /> NAME OF TANK OWNER/AGENT(print) TITLE OF TANK OWNERIAGENT <br /> SAO 1) • � r= `�a <br /> CUPAFORMS(4/99) Formerly SWRCB Form C <br /> i <br />