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09/26/2002 14:40 FAX 425 251 8782 BARGRAUSEN _ 0004 <br /> UNIFIED PICOGRAM CONSOLIDATED FORM T <br /> UNDERGROUND STORAGE TANKS — INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one page per tank) <br /> Page—of— <br /> t.FACILITY IDENTIFICATION <br /> s. <br /> BU$INES$NAMEfsnm<w FACI�trY NAMtm DBA—Dom1 Bu9lneu As) _ <br /> Costco Gasoline Loc-No. 135 496. <br /> ADDRPSS(Pc,ww--fluty) <br /> 3250 West Grant Line,Trarv.CA i. TANK lD#3 an. <br /> FACILITY 1D# <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 419. <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 /> +uo. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> ALL <br /> ® All work listed on the manufacturer's installation checklist has been completed. <br /> 992 <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 4E1• <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> III.TANK OWNER/AGENT SIGNATURE <br /> 1 cemfy that infonnadon provided ha'ein is true and xcntatc to the best of my knowledge. <br /> SIGN A E F OX4ERIAGENT DATE 9/20417- 4". <br /> NAMEO OWNS /AGENT(print) <br /> 415 TITLE TANK 'AN ACE 416. <br /> I A� — <br /> UPCF(1199)Hwfwro-c-112 bnp://www.unidomorx Rev.M6N0 <br />