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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 /> FACILITY ID#(Agency Use Only) <br /> 3 <br /> BUSINESS NAME(Same as FACILDY NAME or DBA-Doing Bioircsv Ao <br /> Costco Gasoline (Loc. No. 658) <br /> BUSINESS SITE ADDRESS Ion CITY IW. <br /> 3250 West Grantline Road Tracy, CA <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aorrly) 483. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SJCEHD #SR0054661 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT September 22, 2008 <br /> [if 5.OTHER <br /> DESCRIPTION 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 /> PLLD and split lines <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4a <br /> Pacific Northern Environmental <br /> CONTRACTOR LICENSE# 4B21, ICC CERTIFICATION# 1059170-U1/VI 48a <br /> 1036142-U1/Vl <br /> 787580 <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 /> by a reRigargd professional engineer hgving education and ex erience with underground storage tanks stem installations. <br /> SIGNA pF TAN OWNER R'S ENT DATE 4g4- PHONE 487 <br /> 2 AW--oDvolri <br /> 10/03/2008 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(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Costco Wholesale Corporation 0 I.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 Rev.(12/2007) <br />