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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 /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME(SameasFACILrfY NAME:or DAA-Doingiiusinah As) 3 <br /> S.M.K.CHEVRON <br /> ADDRESS(ro,i..inseonly) 476 <br /> 25651 N 99 W FRONTAGE RD,ACAMPO,CA 95220-9235 <br /> FACILITY IM j I Jill 111TANKID# 477 <br /> Tank No. 3 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> K 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 /> IN 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 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> CFOD <br /> UPGRADE EXISTING TANK FILL SYSTEMS. ®4 <br /> INSTALL NEW DISPENSERS ON EXISTING CONTAINMENT. <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 E AGENT � DATE2 ® 4S4 <br /> / <br /> NAME OF TANK OWNER/AGENT(print) 485 TITLE OF TANKOWNER/AGENT 486 <br /> HARVINDER PAL SINGH OWNER <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />