Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (ane page per tank) <br /> page_) of_1 <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same a.FACILITY NAME or DBA-Ikring Business As) 3 <br /> S.M.K.CHEVRON <br /> ADDRESS Q or local useonly) 476 <br /> 25651 N 99 W FRONTAGE RD,ACAMPO,CA 95220-9235 <br /> FACILITY IDH I TANK ID rY 477 <br /> Tank No. 2 <br /> IL INSTALLATION <br /> (Check all that apply) <br /> 478 <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 /> 481 <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. L s ®® <br /> INSTALL NEW DISPENSERS ON EXISTING CONTAINMENT. E�� 2 <br /> ENV'RCNT S`ERv CES�y� <br /> FERM <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided b ein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNS A NT Q DATE 464 <br /> NAME OF TANK OWNER/AGE (print) 4a5 TITLE OF TANK OWNER/AGENT 486 <br /> HARVINDER PAL SINGH OWNER <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />