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C� <br /> f?iiF1ED PROGRAM CONSOLIDATED FORM <br /> TANKS FEB 0 5 2007 <br /> UNDERGROUND STORAGE TANKS - INSTAL LATIIVIRaN#v�EfJT HEALTH <br /> CERTIFICATE OF COMPLIANCE PERMiT/Sf&'W� r tank) <br /> Page I—of_I` <br /> I.FACILITY IDENTIFICATION <br /> 3 <br /> BUSINESS N SJ%4E(Same as FACILITY NAME or DBA—Doing Business As) <br /> Costco Wholesale 476 <br /> ADDRESS(For local use on!y) <br /> 3250 West Grant Line Road,Trac ,CA 95376 477 <br /> FACILITY ID# l TANK ID# <br /> 87A <br /> 1I.INSTALLATION <br /> (Check all that apply) <br /> 478 <br /> 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 "79 <br /> with underground storage tank installations, <br /> aso. <br /> ® The installation has been inspected and approved by the Unified Program Agency. <br /> 481 <br /> 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 /> Replaced Phil-Tite Model 85100 spill collector on 87A fuel trank with new Phil-Tite Model 85100 spill collector. <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 /> SIC4NATURE OF TANK OWNEIRJAGENT DATE aaa. <br /> 02/01/07 <br /> NAME OF TANK OWNER/AGENT(print) 484. TITLE OF TANK OWNERIAGENT ash. <br /> Kathleen Henshaw Contractor <br /> UPCF(1199)Hwfwre-c-1/2 www.unidoes.org Rev.02/16/00 <br />