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Alk V % fMw so ' t � UNIFIED PROGRAM CONSOLIDATED FORM TANKS �13 UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Srse,iyreasoa) Sp i awn) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DSA-Doing assure"Aa 3. FACILITY ID: Costco Gasoline Station &W*75e4 �� a LOCATION WITHIN SITE(Optioned) 431 I.TANK DESCRIPTION (A scaled plot plan w iiith the location of the UST system including buildings and landm MPS N mittedto the local ZED TANK ❑Yes)® No 434. TANK ID# TANK MANUFACTURER 2 Containment Solutions If"Yee,"complete one page fm each compartment DATE INSTALLED 439. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 30,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANKUSE 439. PETROLEUMTYPE aaa ® I. MOTOR VEHICLE FUEL ®Ia. REGULAR UNLEADED [12. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hvardoua Materials lnvmtary page) 717 441" ❑ 4. HAZARDOUS WASTE petroleum Hydrocarbon, Unleaded Gasoline 8006-61-9 (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item ovty) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [34. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary rook 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary lank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC E3 8. FRP COMPTIBLE W/100%METHANOL U 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/PIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE UNKNOWN TINGLINING [1 2 1.RUBBER LINED 03 E LINING ❑4.PHENOLIIINING ®b.GUNLINIs- ❑99.OTHER �' DATE INSTALLED ORCOATING 447. INTERIORTANK Check ova item Dol OTHER CORROSION :11.MANUFACTURED CATHODIC P9 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 44s. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfA livable 2.SACRIFICIAL ANODE SPII,L AND OVERFILL 2EOAORBINSTALLED 450. TYPE --TO-VERFILL PROTE 2008EQUIPMENT. YEARINSTALLED 452. (Check all that apply) gg 1.SPILL CONTAINMENT 29 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 'T0� 02.BALL FLOAT 2008❑4.EXEMPT ®3.STRIKER PLATE TONS— IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING [3 99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH Yes L]MATERIAL? 457. gallons UPCF hwfwrc-b(1/99).1/4 www.unidocs.org Rev.02/16/00