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` I • BCE#10199 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency use Only) <br /> BUSINESS NAME(Same.FACILITY NAME or DBA-Doing Business AS) 3 <br /> Costco Gasoline (Loc. No. 38) <br /> BUSINESS SITE ADDRESS 103. CITY 109 <br /> 1616 East Hammer Lane Stockton, CA <br /> :thatapy!1y7!f_483. <br /> LLATION/MODIFICATION PROJECT DESCRIPTION <br /> ff4.UNDER <br /> OJ7(Cheek483. WORK AUTHORIZED UNDER PERMIT 4931 INENT (Number or Date): <br /> G IENT INNT San Joaquin County #SR-0053669 <br /> R STALLATION OR REPLACEMENT <br /> RON OF WORK BEING CERTIFIED: <br /> 483, <br /> Installation of a Healy CAS (Clean Air Separator) , In-Station Diagnostics (ISD) and retrofit <br /> existing gasoline dispensers with Healy Vapor Assist System including Stage II hoses and nozzles. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> Walton Engineering <br /> CONTRACTOR LICENSE# 4811. ICC CERTIFICATION#8010985-V1, 5243762-111, 5256644-U1, 482c. <br /> 5300130-U1,B010904-U1, 5249898-U1, 5297823-U1, 5246984-U1, <br /> 617238 5246959-U1, 5252243-U1, 5300019-U1, 5246958-U1, 8002686-U1, <br /> IV.CERTIFICATION 5246957-U1, 5263219-U1, 5257346-U1, 5257291-U1, <br /> 5290210-U1, 5249892-01, 5252100-U1, 8009649-V1 <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has been inspected and approved by the local agency, or if required by the local agency,inspected and certified <br /> b are istered rofessional engineer havin education and ex eriED a with under ound stora a tank s stem installations. <br /> SIGN TURF OF TANK OWNE R'S ENT DATE 4sa. PHONE 482. <br /> t 10/3/08 ( 425 ) 427-7653 <br /> CERTIF AME(print) 485 <br /> CERTIFIER'S TITLE: 486. <br /> Dennis Bock Costco Wholesale Corporation Compliance Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489_ <br /> Costco Wholesale Corporation [RI L TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />