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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACIL]TY NAME or DBA-Doing Business As) 3 <br /> S.M.K. CHEVRON <br /> ADDRESS 00r local use ony) 496 <br /> 25651 N 99 W FRONTAGE RD,ACAMPO,CA 95220-9235 <br /> FACILITY ID# t TANK ID# 4n <br /> Tank No.1 <br /> H.INSTALLATION <br /> (Check all that apply) <br /> 4� <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 experience 479 <br /> with underground storage tank installations. <br /> 480 <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 487 <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 482 <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 applicable 463 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> UPGRADE EXISTING TANK FILL SYSTEMS. <br /> INSTALL NEW DISPENSERS ON EXISTING CONTAINMENT. u <br /> ON\lRGNA SE.i��1GES <br /> PERM 1 <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK O ER/AGE DATE 484 <br /> i �- ;?- 2- ® ? <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANK OWNER/AGENT 486 <br /> HARVINDER PAL SINGH OWNER <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />