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HomeMy WebLinkAboutBUSINESS PLAN~' gSFIELD ~I ii;. COSTCO GASOLINE Ba Stine Rd _ ~ ,,. Corne_ r of Panam__ a Ln &----`~ ,~~ ~~~ ~'-"~ i ~~~ fl;:. ~ ~ ., ~~~~ ~~~ a~ ~ I~. ~~~~ ~- ~ ~-~~ (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) APPLICATION BUSWESS OWI~R/OPERATORmENTIFICATIONFORM (HAZARDOUS MATERIALS ' '' INFORMATION) BAKERSFIELD FIRE DEPT. Prevention Services a A x ~ >: `. ~ ~ ~ ~-.n 900 Truxtun Ave., Suite 210 FIRE Bakersfield; CA 93301 h DEPARTMENT Tel.: (661) X26-3979/~ Fax: (661) 852-2171 3 ~( 5~ Page 1 of 2 r~ L, FACILITY IDENTIFICATION FACILITY ID NO. ' ' ear egmrrng mo Year Ending 10 BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 B SINESS PHONE 10 Costco Gasoline Loc. No. 643 ~I~/ ~ 3~1~~ ~~¢ Z SITE ADDRESS 10 Panama Lane and Stine Road CITY 1oa Bakersfield CA Ip / 10 ~3 3 DUNN R BRADSTREET ~/ J ~ ~ ~ ~ / ~~ J ~ 1os IC CODE 10 (4 Digit #/) 5541 COUNTY 10 Cobb OPERATOR NAME toe OPERATO Ly ~ ~An^ 11 11 I h ~`~ 1 Costco Wholesale Corporation 4r V V (425) 313-8100 II: OWNER INFORMATION OWNER NAME t11 __ OWNER PHONE 11 Costco Wholesale Corporation (425) 313-8100 OWNER MAILING ADDRESS 11 999 Lake Drive CITY 11a Issaquah STATE 115 Ip 1t WA 98027 IIL ENVIRONMENTAL CONTACT CONTACT NAME 117 _ _ CONTACT PHONE 11 Derinis Bock (425) 313-8100 CONTACT MAILING ADDRESS /~ _tt 999 Lake Drive 5 CITY 1zo STATE 1zi ZIP Issaquah WA 98027 _- -- -PRIMARY IV. EMERGENCY CONTACTS -SEGONDA - NAME 12 AME 12 Dennis Bock Tim Hur-ocker TITLE ~ 12 ITLE 12 Environmental Compliance Manager Operations Manager BUSINESS PHONE 12 (425) 313-8100 BUSINESS PHONE 1 (425) 313-8100 24-HOUR PHON ~~~ ~ ~~ ~~ 12 i 4-HOUR PHONE~~~~ ~~~ - /~~ 131 PAGER No 12 PAGER No 13 13 - - - V. CERTIFICATION - __ __ ___ Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF OWNERlOPERATOR (full printed name) 13 DATE 13 NAME OF DOCUMENT :N'I''3dii:P?(Zeiilti (full printed name) 135 Dennis Bock ~ Z~06 ~/~/a ~j / ~G-f SIGNATURE OF OWNER! \ RlOR DESIGNAT D 13 TITLE OF NER/OPERATORlOR DESIGNATED 138 REPRESENTATIVE REPRESENTATIVE (SIGNER) Environmental Compliance Manager HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIALS ?°°~~~~~_°~°'z' INFORMATION) n~ v~ c. u ti r i e FIRE DSPA R T MEJV r BAKERSFIELD FIRE DEPT. Prevention Services_ r 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 T .: e -3 (1 ~ 'b F (a -26 x 16 71 Page 1 of 1 - - -- -- I. FACILITY IDENTIFICATION __ _ FACILITY ID # (For Office use only -please leave blank) s EPA ID # ~'/-~ ~2 C~6 ~O / ~ DSD (A DBA /FACILITY NAME ~o Costco Gasoline Loc. No. 643 11. ACTIVITIES DECLARATION __ _ -- -- DOES Your Facility ... If Yes, Please Complete ... 12 A. HAZARDOUS MATERIALS 13 1. Have on site (for any purpose) hazardous ~ Yes No es CHEMICAL DESCRIPTION FORM materials at or above 55 gallons for liquids, g HAZARDOUS MATERIALS MANAGEMENT PLAN 500 pounds for solids, or 200 cu. ft. for ~ Yes No Minimum required alannino elements: gency Response Plan e compressed gases (include liquids in ASTs and g Ma s p USTs)? es Training es Prevention 2. Have any amount of an explosive material (other .es Certifications than ammunition) on site? B. REGULATED SUBSTANCES iRS1 131 1. Have on site RS at greater than the threshold ~ Yes No .es CHEMICAL DESCRIPTION FORM planning quantities established by the California g RISK MANAGEMENT PLAN (RMP Submit to USEPA) Accidental Release Prevention program ~ CONSOLIDATED COMPLIANCE PLAN (CeIARP)? ns Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTs) 13 1. Own or operate Underground Storage Tanks? / Yes No ~ UST FACILITY FORM es UST TANK FORM (One Per Tank) 2. Intend to upgrade existing or install new USTs? ~ Yes No ~ UST FACILITY FORM 13 es UST TANK FORM (One Per Tank) z UST INSTALLATION FORM One Per Tank D. TANK CLOSURE /REMOVAL 2. Need to report closing an UST that held hazardous Yes / No a UST TANK FORM (Closure section -one per tank) materials or 3. Need to report the closure !removal of a tank that Yes / No es UST TANK CLOSURE FORM was c{assified as hazardous waste and cleaned on- site? E. ABOVEGROUND PETROLEUM STORAGE TANKS (ASTs) Yes ~/ No es HAZARDOUS MATERIALS MANAGEMENT PLAN 1. Own or operate ASTs above these thresholds; .es Incorporating Federal Spill Prevention Control and any tank capacity is greater than 660 gallons or the Countermeasure (SPCC) Elements pursuant to 40 CFR Parl 112. total capacity for the facility is greater than 1,320 F. HAZARDOUS WASTE EPA ID NUMBER -Provide on this page 1. Generate hazardous Waste? ,/ Yes No g To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than 100 kglmo of recyclable Yes / No vs RECYCLING FORM materials at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable Yes / No as RECYCLING FORM materials at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? Yes / No Ps TP FACILITY FORM es TP UNIT FORM (One per unit) 5. Subject to Financial Assurance requirements? Yes / No es CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a Yes / No zs REMOTE WASTE /CONSOLIDATION SITE NOTIFICATION FORM remote site? FD 2143 (Rev. 09/05) Prevention Services n.. ~ k ~ a , , ,~~ ~ n 900 Truxtun Ave., Ste. 210 FIRE Bakersfield, CA 93301 DEPARTME~IIT Tel.: (661) 326-3979 Fax: (661) 852-2171 ~,; , , Pa°e1 of 2 ,r nrnnr ~ HAZARDOUS MATERIALS MANAGEMENT PLAN r UNIFIED PROGRAM CONSOLIDATED FORMS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIALS INVENTORY NEW ADD ^DELETE REVISE 200 L FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Costco Gasoline Loc. No. 643 CHEMICAL LOCATION //~QO~ ~~(~(n(~ s~~t~'~ J~I~i17~s ( / (' J 201 CHEMICAL LOCATION 20 CONFIDENTIAL(EPCRA) ^ Ye~/ N FACILIT Y I D No. ~ ~ 1 MAP No. (optional) 203 GRID NO. (optional) 20 II'. CHEMICAL I NFORMATION ~ CHEMICAL NAME 20s TRADE SECRET ~Yes~/ No 20 Petroleum Hydrocarbon If Sub'ectto EPCRA refer to instructions COMMON NAME 207 EHS' Yes ~/ No Regular Unleaded Gasoline 20 CAS No. 2pg 8006-61-9 'If EHS is "Yes," all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 I-B FL TYPE -. ^ p PURE a m MIXTURE ~ w WASTE 211 RADIOACTIVE: ~ Yes / No 21 ~ CURIES 21 ' PHYSICAL STATE ? s SOLID ~ I LIQUID ? g GAS 214 LARGEST CONTAINER 21 30,000 Gallons z1 FED HAZARD CATEGORIES ~ 1 FIRE ~2 REACTIVE ~ 3 PRESSURE RELEASE ~ 4 ACUTE HEALTH ~ s CHRONIC HEALTH Ch k ll th l ( ec a at app y) ANNUAL WASTE AMOUNT NSA 217 MAXIMUM 218 DAILY AMOUNT 30,000 AVERAGE DAILY AMOUNT 219 10,000 STATE WASTE 22 CODE 4 UNITS ^/ ga GAL ^ d CU FT ~ Ib LBS ~ to TONS 221 222 DAYS ON SITE 365 f EHS, amount must be in lbs. STORAGE CONTAINER (Check alt that apply) ~ a ABOVEGROUND TANK ? f CAN ? k BOX 22 ? pTANK WAGON b UNDERGROUND TANK ? g CARBOY ? I CYLINDER ? q RAIL CAR ? c TANK INSIDE BUILDING ? h SILO ? m GLASS BOTTLE ? r OTHER ? d STEEL DRUM ? i FIBER DRUM ? n PLASTIC BOTTLE ? e PLASTIC/NONMETALLIC DRUM ? j BAG ? o TOTE BIN STORAGE PRESSURE ~ a AMBIENT ? as ABOVE AMBIENT ? ba BELOW AMBIENT 22 STORAGE TEMPERATURE ~ a AMBIENT ? as ABOVE AMBIENT ? ba BELOW AMBIENT 22 ? c CRYOGENIC ~ %WT HAZARDOUS COMPONENT EHS CAS # 1 15% 2zs METHYL TERT BUTYL ETHER 227 ? Ye~/ No 2za 1634-04-4 2z z 15% z3o TOULENE z31 ? Yes~No z3z 108-88-3 z3 3 21% 234 XYLENE 23s ? YesaNo z3s 1330-20-7 23 4 5% 238 BENZENE z3s ? Yes~No zoo 71-43-2 241 s 5% 24z 1,2,4 - TRIMETHYL BENZENE 243 ?Yes ,/ No 244 z4 g5$3$ IIL SIGNATURE . PRINT NAME 8 TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE h~%S ~~ ~J~ L~03n~ /r~i lGn ~' ~/ . 24 ~~~~ U~ z do ` ~S~ 6 ' FD 2144 (Rev. 09/05) ~r nnrar ~ HAZARDOUS MATERIALS MANAGEMENT PLAN r' UNIFIED PROGRAM CONSOLIDATED FORMS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIALS INVENTORY NEW v ADD ~ DELETE T REVISE 200 E ~~ ..~ r x > r ~ i .~ _._. FIRE DEIPAR7ME~1T Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Paae1 of 2 I. FACILITY.INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) Costco Gasoline Loc. No. 643 CHEMICAL LOCATION-/ 's 201 u ~(/C~ ~r r0 ~`f~ "~~f/YLt ~1 e ~`f ~ / CHEMICAL LOCATION 20 CONFIDENTIAL (EPCRA) ? Ye~N FACILITY ID No. 1 MAP No. (options!) 203 GRID NO. (optionap 20 I II. CHEMICAL INFORMATION CHEMICAL NAME 205 20 Petroleum Hydrocarbon TRADE SECRET ? Yes~No ' ect to EPCRA referto instructions If Sub COMMON NAME 207 EHS" ? Yes ~/ No Supreme Unleaded Gasoline zo CAS No. 209 "If EHS is "Yes," all amounts below must be 8006-61-9 in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 I-B FL TYPE 211 ^ p PURE ~ m MIXTURE ~ w WASTE 21 RADIOACTIVE: ^ Yes ~ No CURIES 21 LARGEST CONTAINER 21 PHYSICAL STATE ? s SOLID ~ I LIQUID ? g GAS 214 30,000 Gallons z1 FED HAZARD CATEGORIES ~ 1 FIRE ~2 REACTIVE ~ 3 PRESSURE RELEASE ~ 4 ACUTE HEALTH ~ 5 CHRONIC HEALTH (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 DAILY AMOUNT STATE WASTE 22 CODE AMOUNT NSA DAILY AMOUNT 30,000 10,000 221 222 n UNITS ~ ga GAL ^ ~{ CU FT ~ Ib LBS ^ to TONS DAYS ON SITE EHS, amount must be in lbs. 365 22 STORAGE CONTAINER (Check all that apply) ? a ABOVEGROUNDTANK ? f CAN ? k BOX ? p TANK WAGON b UNDERGROUND TANK ? g CARBOY '? 1 CYLINDER ? q RAIL CAR ? c TANK INSIDE BUILDING ? h SILO ? m GLASS BOTTLE ? r OTHER ? d STEEL DRUM ? i FIBER DRUM ? n PLASTIC BOTTLE ? e PLASTIC/NONMETALLIC DRUM ? j BAG ? o TOTE BIN 22 STORAGE PRESSURE ~ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 22 STORAGE TEMPERATURE ~ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC - __ - T- - -- ---- ~ -- ~ %WT HAZARDOUS COMPONENT EHS CAS # - -- - - 1 _. 15% z2s - __ _ - METHYL TERT BUTYL ETHER 227 ? Ye ~ No 2z8 -- 1634-04-4 z2 2 15% 230 TOULENE z31 ? Yes ~ No zs2 108-88-3 23 3 21% 234 XYLENE z3s ? Ye_/ 0 23s 1330-20-7 z3 4 5% 238 BENZENE 2ss ?Yes / No zoo 71-43-2 241 5 5% 242 1,2,4 - TRIMETHYL BENZENE 243 ?Yes / No 244 g5-63-6 24 ~ IIL S16NATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE ~-'DA~E 246 FD 2144 (Rev. 09/05) n ti (HMMP) t-1A~ARI~t}US MA~'EFZIALS MANAGEII~~N'1' PLAN ~rE'r ~~~~.~~~ ~~~~~o~~ T'c~; e 3 c? f' Prev~ntian Servie~s ;~ 30O'I'r~ xi~~:~r~ r'1~,re., 5i~ii°r. 21.0 h , t~ , : 13~~1cc:~z-s(ic~lr1, C::1 x::3,301. ~R~ ~'Il i;7 1 s" 7"cl.: (Fi61_j 32~i-;'r~~ 70 ~~ax: (kaFi1) X52-2 i. (1 ,_ ___- ~ ~I~~ C}IA~RAi~i ~~ ___ _______ ~Pt~ILI"fY Q1A~RI~~Ii ~.. ~ . ~ .... .. _....~._.._s __P____~..~~... __._.._--.--.._._..__.___~___ os co aso ine C~oc. ~~To.`843~"`"""~""~'~" Business Name: Coslcp Gaspline Lpc: Np. 6413 ~.._. ~ ~ _ ._.n ... Panama Lane~erid Stine Road,~Bakersfield, CA"~ Busin~s;~ ~dclre~~: PanG~rnti~ Lana ~anci Mine Rpad, I3akarsiield, CA .-.__..J _.. Gi~.~ ~i:QA~s ti Ef:~~ ,f }n~t°C`C1~1 I( ~~,1t"~~C3t.}~ ~._ ~, }'" '~ lF _ ~ ~i~,~.~ 3 ~~* '-~' ~°~-~ f r;>ase i~~strc~~e d~irrctiort of t~~orth ~~ t ~D 217Q ~f2~~. 0~,'o5t t ~ ~. L~...:I (HMMP) HAZARDaUS MATERIALS MANAGEMENT PLAN BAKERSFIELD FIRE DEPT. Prevention Services ~_ . ~ r ~ s ~ , r•,-r. ._n 900 Truxtun Ave., Suite 210 INSTRUCTIONS F~RF sakersfield, CA 93301 S{TE 8~ FACILITY DIAGRAM DEP.4RTME11tT Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 2 of 2 T h sr insr u dionse xplain th eu s; of Ii esited i~ ram aid th efacility did ram. Normally, small ~ d mai ium size busin else swill only hav etoB b mit a sted iag ram. If you hav eisb d ividd your busin ~s into smaller areas b a'c~i sr of fi e~ mploc ity ors ize, thn you will b em mpleting aid al d itional d Qail mqi ,facility did ram, for each of fi ~ areas. In dude insr u lions th atls o w th eroute to your busin ~s if it is in aremote to anon. All ding rams must beon 8 ''/2" x .11" pp ~ aid drawn using a ~ aight ai g etool . SITE DIAGRAM INSTRUCTIONS T 13 sted i~ ram isu sd toh o w your busin sand to indicate thebusin use sth ~ immal iately a rround your proper ~, ua ally within 300 feet. If you will b ~ o wing l~ ecif is area d fail on facility did rams, usr th esite ding ram to h o w al o v aall l~r o ut of fi ep lai t . If you will not b eB b miffing facility did rams, th e site m~ must in dude all of h efollowing information: 1. Ch alc thebox on th etop leftm rn a of fi eform provid~i th ~ indicatal "Site Did ram." 2. Pr nt th en aneo f your busin mss, a s shown in your 1HI M P, on th etop of fi ed i~ ram. 3. Lab el th elo anon of fi eh a~dous mater alsand idaitify th an by name and typeo f h azar'd ( ie., flammdi le liquid, ~ rrosiv es lid). 4. Lab d th elo cation of utilityh u toff points fir g a~, electr is and waters ervices. 5. Lab d th elo anon of fr ehydrai ts. 6. Lab el por ti~ns~ f fiebuilding protectal by aitomatic ~riiklers ystems. 7. Lab el th edr ection rqi re sr nting nor fi on th ed i~ ram. (T halm ram form provid ai in dude s an o r fi arrow). . 8. All lab eling and id ~ of bation on th e d i~ ram must b e 1~ ible and easily under tan d ~ le at the sr a le is b miffed . Did rams must b e a fficiai tly 1~ ible to produce a l~ ible copy. Try to ar o id th eu sr of ~ b raT iations~ rs ymbols. If you must usr th an, provid a alb ai d ec p laining yours ystem. M~ s may b ereturn ai for ei rrection f you fail to follow th ~ insr- u dons. FACILITY DIAGRAM INSTRUCTIONS Facility dim ramsa re sipplemai is to th esited izg ram. Usr th an toh o w th asb d ivision detailso f a larg e busin mss. 1. Ch alc th eb ox in th eu p p a• right h an d ©rn a of fi eform provid ai th ~ indicated "Facility Did ram". 2. Pr nt th en aneo f your busin ~s a s shown on your ]6I M P. Pr rit then aneo f fi e area th a: this m~ rqi re s; nts. T loai ame Mould be th es~ me n ame th ~ you usr d on this a rea's inval tory r~ o r t 3 . Indicate whidi area th ed i~ ram r~ re sni is a nd th etotal numb a of facility ding rams th ~ you are in duding. If a map rqi re sr nte3 th efi• st of four areas, it would be lab ell # 1 of 4. 4. F dlow insr u lions (i -8)* fors ited i~ rams peg arding th ep ecif ivd etails to be in dudai o n ~ facility did ram. UNDERGROUND STORAGE TANK FACILITIES PLEASE NOTE: * If you operate an Underground Storag e Tai k (UST) facility, th efacility ding ram h all als p ecf y th e to ation(s) of fi eUST ©n tinuous leak monitor ng ~ hem aid /or fi elo ation(s) wh ae th eUST monitor ng will b ep aformai . FD 2170 (Rev. 09!05 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OF COMPLIANCE (one page per lank) Page _ or _ I. FACILITY IDENTIFICATION BU$INES$ NAME (Same as FAQI.I?Y TFAMIS or DBA -Doing Business As) ~ Costco Gasoline ADD[2ES5 (For wcai sae onty) 476 1VWC Panama Lane and Stine Road, Bakersfi2Zd,;:::CA FACILITY ID# ~~'~1,i „' '; ;< t TANK ID # 4n II. INSTALLATION . {Check all that apply) The installer has been trained and certified by the tank and piping manufacturers. 478 ^ The installation has been inspected and certified by a registered professional engineer having education and experience a'~ with underground storage tank installations. The installation has been inspected and approved by the Unified Program Agency. aso All work listed on the manufacturer's installation checklist has been completed. Oat [~ The installer has been certified or licensed by the Contractors' State License Board. aaz ® The underground storage tank, any primary piping, and secondary containment was installed according to applicable 481 / voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: III. TANK OWNER/AGENT SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. S[GNATUR OWNER/AGENT DATE O~ z~/~~ / (o 4a4 NAME OF OWNER/AGENT (print) 4as TITLE OF TAN OWNER/AGENT 486 Dennis Bock Costco Wholesale Cor oration Com liance Mana er UPCF (1/99 revised) 14 Formerly SWRCB Form C tt UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OR COMPLIANCE (one page per leak) Page _ of L 1~ACILITY IDENTIFICATION BUSINESS NAME (Same az FAC2ITY NAME or DBA -Doing Busimss As) 3 Costco Gasoline ADDRESS (For lacat use onty) 476 NWC Panama Lane and Stine Road, Bakexsfield,~:":CA FACILITY ID# a~ ~ ~ ~~~~ :~ s ^• ~ TANK ID # 477 ~~ ~rK`~) II. INSTALLATION (Check all that apply) 478 The installer has been trained and certified by the tank and piping manufacturers. ^ The installation has been inspected and certified by a registered professional engineer having education and experience 47' with underground storage tank installations. The installation has been inspected and approved by the Unified Program Agency. 480 A11 work listed on the manufacturer's installation checklist has been completed. 481 The installer has been certified or licensed by the Contractors' State License Board. as2 The underground storage tank, any primary piping, and secondary containment was installed according to applicable as3 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: III. TANK OWNER/AGENT SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE KOWNER/AGENT DATE ag a~ z~J~ 484 NAME OF T OWNER/AGENT (print) 485 TITLE OF TANK OWNER/AGENT ase Dennis Bock Costco Wholesale C.or oration Com liance Mana er UPCF (1l99 revised) 14 Formerly SWRCB Form C +. UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OF COMPLIANCE (one page per took) Page _ of _ I. FACILITY IDENTIFICATION BU$1NE$S NAME (Same as FAC[LTTY NAME or DBA -Thing Business As) 3 Costco Gasoline ADDRESS (For local use onty) 476 NWC Panama Lane and Stine Road, Bakersfield,C;CA FACILITY ID# I TANK ID # 477 II. INSTALLATION (Check all that apply), 476 The installer has been trained and certified by the tank and piping manufacturers. ^ The installation has been inspected and certified by a registered professional engineer having education and experience a7s with underground storage tank installations. aso The installation has been inspected and approved by the Unified Program Agency. asl All work listed on the manufacturer's installation checklist has been completed. 482 The installer has been certified or licensed by the Contractors' State License Board. The underground storage tank, any primary piping, and secondary containment was installed according to applicable °B3 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: III. TANK OWNER/AGENT SIGNATURE f certify that the information provided herein is true and accurate to the best of my know]edge. SIGNATUR ~ O'~NT ~~ DATE ~ ~ zs/~~~~ 4sa NAME OFT K OWNER/AGENT (print) 485 TITLE OP TANK OWNER/AGENT 4se Dennis Bock Costco Wholesale C.or oration Com liance Manager UPCF (1/99 revised) 14 Formerly SWRCB Form C