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`. 1J BCEI#10050Jq <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1 {� �� 21 1 �Z ` " , r— <br /> UNDERGROUND STORAGE TANK l 6 )I �l <br /> OPERATING PERMIT APPLICATION -FACILITY INFOR ON evP <br /> (One torn per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT N S.CHANCE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> ?Check unenem only) <br /> ❑ 3.RP.NT:WAI.PERMIT ❑ h.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> 101 AL NUMBER OE US Is A I F.A('11.11 Y' J°, FACIurY IDnn <br /> 3(Existing)and 1 (Proposed)-4Total MKI"(IUbcOIV) � hF — 1016111 - 131811 <br /> III'SII:FSS\Ah1F.lsa —IN(aur) 'AW 11111% 1N-1Hu11—A,i <br /> Costco Gasoline(Loc.No.858) fJ Jrlei <br /> III SIM SS SI I L ADDRESS 1^` CITY <br /> 3250 West Grant Line Road Tracy <br /> I WII I'll"I YPIQ I.MOTOR VI HICLP.1:111 1 ING ❑ .'..FUI I. DISIR11311TION b the facility located on Indian Reservation or , <br /> 3.FARM 4.PROCESSOR ❑ (r.OTHER Trust lands'? ❑Y•cs 0 No <br /> If. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME "'' PHONE <br /> Costco Wholesale,Attention: Licensing ( 425 ) 313-8100 <br /> \LMI.ING \DDRISS — <br /> P.O.Box 35005 <br /> l'll'1' 111) 1 STATE ,n ZIP(OI)l. <br /> Seattle Washington 98124 <br /> III. TANK OPERATOR INFORMATION <br /> r.\NK 01'FRATORN NMI 121IIHONI- <br /> Dennis Bock,Costco Wholesale ( 425 ) 313-8100 <br /> M NILING ADDRESS <br /> 999 Lake Drive <br /> t H N +'N-+ STATE +=`` ZIP C'ODI <br /> Issaquah Washington 98027 <br /> W. TANK OWNER INFORMATION <br /> TANK U\\NER NAME +i+ PHONE <br /> Costco Wholesale,Attention: Licensing ( 425 ) 313-8100 <br /> MAILING ADDRESS <br /> P.O.Box 35005 <br /> t"IlY Ar STATE +Ia ZIP(()it[ <br /> Seattle <br /> IP(()it[Seattle Washington 98124 <br /> DA NER 1'YPF:: ❑ 4. I(n \I ACI M DNIRK I' ❑ 5 CO('N'I'Y A6FN('\" ❑ h.S'I.A'1'1;AGENCY +' <br /> ❑ i,FEDERAL AOEN('Y ❑e K NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)IIQ 44- 10 3 19 11 10 10 1 ('all the State Board of Equalization.Fuel Tax Division,if there an questions. <br /> VI. PERMIT HOLDER INFORMATION <br /> INaue pram)and send legal nntilicumms and mailings to. ❑ I FACILITY OXV\FR ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> mr. <br /> SUPERVISOR OF DIVISION,SECTION.OR(1FFICF.I Rvywad For Public:1grnaa Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify ha c information provided herein is true.accurate,and in full compliance with legal requirements. <br /> NLU. u' \I <br /> 107 -Le' �. PHO425 ) 313-8100 I^ <br /> APPLU ANT NAW Ipnno '- APPLI( .141 1111 ' � - i•. <br /> David H Rogers Director of Real Estate Development <br /> t PCF UST-A Rex.112/2907) _-... <br />