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03/25/2004 14:47 2094760276 COSTCO WHOLESALE : PAGE 02 <br /> 04 12127 FR COO GPSOLINE 425 427 7119 TO 91*79027G P.Ovol <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS —INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (one Page per wa) <br /> Page Z or 73 <br /> I.FACILITY IDENTIFICATION <br /> BUS 5S SAM "•>w.v Pn' race>.oaa_a.,.eew.w,w <br /> � Lis Asv�ti <br /> ADORnss mb- „ L�•vE �n aA ,fzla a <br /> FACILITY IDN TANK IO II_ lir. <br /> IL INSTALLATION <br /> (Check A that epplyl <br /> r.e. <br /> 3KThe installer has been trained and certified by the tank and piping manofacrurvrs. <br /> ❑ The installation has been inspected and cenined by a retpstered professional engineer having education and experience <br /> with underground storage tank installations. <br /> .a <br /> Qr The installation has been inspected and appro,ed by the Unified Program Agency. <br /> uk. <br /> 3---<1 work listed on the manuf'acrurer'>installation checklist has been completed. <br /> t�r <br /> ear� 4i <br /> The installer has been certified or licensed by the Contractors'State License board. <br /> T710 underground storage tank% any primary piping, and secondary containment was installed according to applicable ws. <br /> voluntary consensus standards and written manu(aenmer's installation procedures. <br /> Description of work being oertificd: <br /> &W Cl ��'v GIST <br /> Ell.TArsx OWNUTAGENT SIGNATURE <br /> I rlintfy thu ate Mronnittioo pm.ldM herein u true lied aocurUo to the bort or my knorleage. <br /> STGNA711R8 OF { EX/AOEVi^ GATE 'J /2�/�4 � +w <br /> NAME OF TANK OwNEtUAGCNT(print) ties. TITLE TANK OwNEP/.0.GETrT "u <br /> h <br /> VrCF(if")trwrwrc<-1rs mrodr.'ww.NMdoq.Ntx RN•.VIVI000 <br /> * TOTAL PAGE-01 +ek <br />