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09/20/2002 14:40 FAX 425 251 8782 BARGHAUSEN fd <br /> 003 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANW <br /> UNDERGROUND STORAGE TANKS - INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (Otte page per tank) <br /> Page_OF_ <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAME[.Some m FA('tLftY NAME m DBA-M.,8ne'mes M) 3' <br /> Costco Gasoline Loc.No. 135 <br /> ADDRESS[r4rmw ce: .4 >7 4te. <br /> 3250 West Grant Line.Trac CA <br /> FACILrrY IITIt I TAN K ID#2 4n• <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 4n. <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 47 <br /> 4. <br /> with underground storage tank installations. <br /> 4eo. <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 411 <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 4M <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 All. <br /> voluntary eonsetrsus standards and written manufacturer's installation procedures. <br /> Description of work being cerrified: <br /> III.TANK OWNER/AGENT SIGNATURE <br /> I certify ntat theormation provided hereat is true and acerata to the best of my knowledge. <br /> SIGNATUR O O AGENT DATE <br /> NAMED 'KO AGENT(prim) 4u. TrrLp TAN OWNER/AGENT' 4%. <br /> G 1 — <br /> UPCF(1/99)Hwfwrn-c-L2 http://www.avidoes.org Rev.03116/00 <br />