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a A <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -INSTALLATION <br /> CERTIFICATE OF COMPLIANCE (one page per tank) <br /> Page_of <br /> I.FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Costco Wholesale Fuel Center <br /> ADDRESS(For local use only) 476 <br /> 2680 Reynolds Ranch Parkway <br /> FACILITY ID# l TANK ID# 477 <br /> 652500 <br /> II.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> ❑x The 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 education and experience 479 <br /> with underground storage tank installations. <br /> Oso <br /> The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> Q All work listed on the manufacturer's installation checklist has been completed. <br /> 482 <br /> ® The installer has been certified or licensed by the Contractors' State License Board. <br /> ® The underground storage tank,any primary piping,and secondary containment was installed according to applicable 483 <br /> voluntary consensus standards and written manufacturer's installation procedures. <br /> Description of work being certified: <br /> Installation of(1) 30,000 gallon "Containment Solutions" double wall fiberglass Underground Storage Tank. <br /> III. TANK OWNER/AGENT SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TANK OWNER/AGEN ® DATE 484 <br /> 05/25/2011 <br /> NAME OF TANK OWNER/AGENT(print) A 7485 TITLE OF TANK OWNER/AGENT 486 <br /> Ted Rodriguez,Jones Covey Gro ,Inc. Project Manager <br /> UPCF(1/99 revised) 14 Formerly SWRCB Form C <br />