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�u�L _ l cr ✓ <br /> l /q,, ✓ <br /> IED PROGRAMCCONSOLIDATED FO . <br /> TANKS ( �Z <br /> UNDERGROUND STORAGE TANKS - FACILITY3�8 <br /> (One page per site) <br /> TYPE OF ACTION V1.NEW PERMIT ❑3.RENEWAL PERMIT 115 CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check om item only) [14.AMENDED PERMIT (Specify change) ❑S.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> L FACM]TY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACrtrfYNAME or DBA-Daus Basin.Ae) 3, FACILITY <br /> Costco Gasoline Station ID# 1' <br /> NEAREST CROSS STREET �I 401. FnACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 402. <br /> Highway 120 and Daniels Street/ MAwTr�A W1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS [;3 1.GAS STATION ❑3.FARM V S.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. "If owner,of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust laynyd� fs? oce which operates the UST. (This is the contact person for the tank records.) <br /> 3 New ElW <br /> Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> Costco Wholesale Corporation (425) 313-8100 <br /> MAILING OR STREET ADDRESS nay. <br /> 999 Lake Drive <br /> CITY 410. STATE 411. 22P CODE 412. <br /> Issaquah WA 98027 <br /> PROPERTY OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Costco Wholesale Corporation (425) 313-8100 <br /> MAMING OR STREET ADDRESS 416. <br /> 999 Lake Drive <br /> CITY 417. STATE 418. ZIP CODE 419, <br /> Issaquah W-4 98027 <br /> TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420, <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TYTY, HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ¢'3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check me box to indicate which address should be used fm legal notifications and m.lung, <br /> Legal notificationa and mailings will be scat to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY V2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is We curate the beat of my knowledge. <br /> SIGNATURE OF APP CAf DATE 424 PHONE 425. <br /> 1 (425) 313-8100 <br /> NAME OF APPLICANT ' t 426. TITLE OF APPLICANT s'IN 427• <br /> Dennis Bock Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(A,.1, oaiy7 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ase only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 www.anidocs.org Rev,02/16/00 <br />