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_ 03/25/2004 14:47 2094780276 COSTCO WHOLESALE : PAGE 01 <br /> MAR 25 '04 12:27 FR COO GASOLINE 425 427 7119 TO 91780276 P.01i01 <br /> UNIFIED FROGRANI CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (Ona pnge Per lark) <br /> Page y ar,� <br /> 1.FACILITY IDENTIFICATION <br /> BUSINESS NAM <br /> ADDRESS Ila,amiwe.aly/ <br /> t.- <br /> 1:ft/V J � ^"rYV �f.�.•�lG�`� '• 9S.L/�ara. <br /> Rd/ /II <br /> WATrY IDe TAMC M ft <br /> II.INSTALLATION <br /> iChmi,all that apply) <br /> •a. <br /> MI-<8 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 ing education and experience an <br /> with underground storage sank installations. <br /> al"fNo. <br /> he insrallatiod has been inspected and approval by tic Unified Program Agency. <br /> All work listed on the nufacmrer's installation checklist has been completed. at. <br /> d. - <br /> i <br /> L,',��, '1``�6o installer has been certified m licensed by the Contractors'State License Board. <br /> i.{�"rne underground storage tank, any primary Piping, and secondary containment was installed according to appiiabh: •a3. <br /> voluntary consensus standards and wtmen manufacturers installation procedures. <br /> Description of work being terrified: <br /> g�<�� <br /> III.TANK OWNER/AGE-NT SIGNATURE <br /> t senitY that the infnntTatiaa Provided hanin is tru.and we.ntte to d+a ban of my knowladge. <br /> gtGNATUR OF TANK OWNENAGENT PATS �.t,^� ar <br /> NArd.eO KOwNEWACGNT,,��P¢,,nnt) • TITLFRRF TANK OWNER/AOEN •a{ <br /> -D e vl r1 i- (So LOfr /l6nGCQ Gr <br /> tIPCF fr/9Y)Hwfwrat-1R hl ://www.aMdoc•.a <br /> ro R Rev,aZ/16/00 <br /> ** TOTAL PAGE-01 ** <br />