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BCE#10050 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/ MODIFICATION <br /> (One form per project.) <br /> 1. FACILITY INFORMATION <br /> FACB.ITY ID#(Agency Use Only) t <br /> BUSINESS NAME(Same u FACMI NAMEm DBA—Doing Buei SM) <br /> Costco Gasoline (Loc. No. 658) <br /> BUSINESS SITE ADDRESS to3. C1'17 tB4 <br /> 3250 West Grantline Road Tracy, CA <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aonlvl 483a WORK AUTHORIZED UNDER PERMIT 463b' <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SJCEHD 4SR0054661 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT September 22, 2008 <br /> 5.OTHER <br /> DESCRMTION OF WORK BEING CERTIFIED: 483c <br /> Installation of a Healy CAS (Clean Air Separator) , In-Station Diagnostics (ISD) and retrofit <br /> existing gasoline dispensers with Healy Vapor Assist System including Stage II hoses and nozzles. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482.. <br /> Pacific Northern Environmental <br /> CERTIFICATION# <br /> CONTRACTOR LICENSE# 4am. ICC 1059170-u1/VI 482c, <br /> 787580 1036142-U1/VI <br /> 1073671-U1/VI <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> bv a re 'stered orofessional engineer having education and ex erience with underground storage tank system installations. <br /> SIGNA K OR+ti£R-9R-9R4FRI�S A ENT DATE — I PHONE 487. <br /> 12/2/08 ( 425 ) 427-7653 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> Dennis Bock Costco Wholesale Corporation Compliance Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DHA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Costco Wholesale Corporation <br /> ® 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />