Laserfiche WebLink
' Y BCE #10050 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (Onc roan per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT D S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (C'heak u,w AM only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PF.RIA T <br /> L FACILITY INFORMATION <br /> TOTAL NtJNIBFR OF USTs AT FACILITY 101 <br /> FACH.ITY ID# <br /> 3(Existing)and 1 (Proposed)-4 Total (Age'Nq'U,CP OnI} <br /> BUSINESS NAME is --eu'n lry aANII-0m PAII lh.m...,k,i <br /> Costco Gasoline (Loc.No.658) <br /> BUSINESS SII'L ADDRUS5 1a' C'ITY w, <br /> 3250 West Grant Line Road Tracy <br /> FACILIIY TYPI' IM I.MOTOR VF,HICLF.FUELING ❑ 2.FURL DIS'MIBUTION SII ie the facility located on Indian Reservation or ur <br /> ❑ 3.FAR.N1 0 J.PROCESSOR ❑ 6.OTHER Tnast lands'1 ❑Yes M No <br /> If. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40, PHONE <br /> Costoo Wholesale,Attention: Licensing 425 313.8100 <br /> MAILING ADDRESS <br /> P.O.Box 35005 _ <br /> (I1.), .m,. SrATE "' -ZIP CODE - - <br /> Seattle Washington 198124 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPFRATOR NANIF °'"I I'IiONI= <br /> Dennis Back,Costco Wholesale ( 425 ) 313-8100 <br /> NIAII NO ADDRESS - <br /> 999 Lake Drive <br /> C.LL)• ,za.+ SIAIF <br /> r<.5 ZIP Cow; <br /> Issaquah Washington 98027 . <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME +'+ PHONE <br /> Cosico Wholesale,Attention: Licensing ( 425 ) 313-8100 _ <br /> MAULING ADDRESS <br /> P.O.Box 35005 <br /> CITY ,Iv STATE +'s ZI11 'ODE <br /> Seattle Washington 98124 <br /> OWNUR]WE: ❑ 4.LOCAL AUENCYIDIS"rRICT ❑ 5.COLINTY AGE'NC'Y ❑ 6.S'TA'TE A(ih.NCY -' <br /> ❑ 7.FEDERAL AGENCY M 8.NON-GOVERNAIEN'T <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 19 1 0 O Call the State Board of Equalization,Fuel Tar Division,if them are questions. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit:nIJ send legal notifications and mailings to: ❑ I.FACILITY 4NVNEl( [14.TANK OYE]tAT01( <br /> M 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406, <br /> SUPERVISOR OF DIVISION,SF('r1ON.OR OFFICE IRcgnireJ Fol Public Agcnrice Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICAT[ON: I cern ha is information provided herein is hvc.accurate,and in full comp)inner Isifh legal rviluirenients. <br /> APPLILANI } -NATIO F DA I7= 4)t. PHONI: 425. <br /> 10 1 2(p ( 425 ) 313.8100 <br /> AI'1'I WAN I N.\\ AI'FI I(':W"FITIT, " <br /> David H Rogers Director of Real Estate Development <br /> (Pr:F VST-A Rev.021201m <br />