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_ _0_3/25/2004 14:47 2094780276 COSTCO WHOLESALE : PAGE 03 <br /> ncP. 25 '04 12:27 FR *CO GASOLINE 425 427 7119 TO 91*790276 P.91i01 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE <br /> (One PNV per tank) <br /> jFaae�fir <br /> 1.FACILITY IDENTIFICATION <br /> BUS7NEss�°ypE c�avneRm•e�. ..o'i.-o..y 9.u..,.ai � ' <br /> ADDRESS{Rr ro«wr aHyl .+s <br /> .v LANd ZVv 0 <br /> .4 _/kq <br /> FACILITY IDK i '� � TANK ID n n-. <br /> IL INSTALLATION <br /> (Cheek alt Mar x"55) <br /> a <br /> The installer has bee,trained and rxrhfied'oy the tank and piping manufacturers. <br /> ❑ The installation bas been inspected and certified by a registered professional engineer having education and experience in <br /> with underground storage tatilt installations. <br /> ea <br /> The installation by beer.inspected and approved by to Uniticd Program Agency. <br /> ui <br /> All work lisred on the manufacmrex's installation checklist has been completed. <br /> ID installer has been certified or licensed by the Contractors'State License Hoard. +a. <br /> The underground storage tank, say primary piping, and secondary containment was installed according to applicable <br /> voluntary consensus consensus standards and written manufacturers installation procedures. <br /> Description of work being certified' <br /> IM TANK OWNERlAGENT SIGNATURE <br /> I aanify taxi the atrmtnanoa pmided herein b Me and mcnrdte m die bac or any Imowled e. <br /> s <br /> SlG,NATURE,Q!X,ANVwNEWAOEvT DATE 3/Z5/ ur <br /> NAMPOF TAN w WALL•"NY(Yrinp TITLE OF TANK OWNER/NOENT °•x <br /> Bv1ki 15 (2,A <br /> UIFU(1199)NwMrct-tR bMp;Uwww,anidouery <br /> Re..OTllbea <br /> * TOTAL PAGE.01 ** <br />