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0 3 - qw Mw - UNIFIED PROGRAM CONSOLIDATED FORM ( MtJ TANKS �i3IOg r�$ UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERM T ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify seamy) ❑ 8.TANK REMOVED BUSINESS NAME(Sameae FACIL=NAMEof DBA-Doing Business As) 3. FACILITY ID: L Costco Gasoline Station /r� ,L%L',q C/j g LOCATION WITHIN SITE(optioned) 411. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK qq []Yes No 434. 3 p� Containment Solutions If"Yes;'complete one pageforeach compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 30,000437. 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440, ® 1. MOTOR VEHICLE FUEL Iff la. REGULAR UNLEADED��g/ [12. LEADED [15. JET FUEL tr (If checked,complete Petroleum Type) 14 lb. PREMIUM UNLEADED V' ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (Wm Harmdoua Materiels Inventory page) 441' CAS#(from Hazardous Matmials Inveranav e) 442, ❑ 4. HAZARDOUS WASTE (Includes Used Oil) petroleum Hydrocarbon, Premium Gasoline 8006-61-9 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check ane item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [34. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL,-prim-primary tank tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 13 95.UNKNOWN 4-u. (Cheek one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS IN 8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIHERGLASS/PLASTIGE3 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTRER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑L RUBBER LINED [13.EPDXY LINING S.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED [199.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER IfA licablc ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 2008 ®1.ALARM 2 0 0 8❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2u6g ®2.BALL FLOAT 2008❑4.EXEMPT ®3.STRIKER PLATE 7U79- 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 a0 that apply) (Check me 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 ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MONAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 www.unidocs.org Rev.02/16/00