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1anK4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form cru 4 u <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this seccti 5.CHANGE OFon and Sections INFORMATION <br /> below) <br /> I.NEWPERMIT C1 3.RENEWAL PERMIT <br /> ❑.6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSBURE ON SITE ❑ 8.UST REMOVAL 4306 <br /> 43 <br /> DATE LIST PERMANENTLY CLOSED: DATE BXISTING UST DISCOVERED: <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use only) - - <br /> 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Business Aa) <br /> Costco Gasoline(Loc.No.658) la <br /> HUS MSS SITE ADDRESS 107 CRY <br /> 3250 West Grant Line Road Trac <br /> H.TANK DESCRIPTION <br /> TANK J� <br /> 1D �3 432 TANKMANUFACIVRER 433 'TANK CONpIG11RAT[ON:TEIs TANK18 434 <br /> TNQ ®I.A STAND-ALONE TALAR <br /> Fi L J J Containment Solutions ❑2.ONE INA COMPARTMENTED UMI. <br /> Com Iv1v w° farcech cam lin Wcwil. <br /> DATE LIST SYSTEM INSTALLED 43S - TANK CAPAY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> CIT <br /> TBD 1,500 1 <br /> III.TANK USE AND CONTENTS <br /> TANKUSE ❑ Ia MOTORVEHICLEFUEL)NO ❑ Ib.MARINAFUELINO ❑ Ic.AVIATION FUF.LINO 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ind da Uud00) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281.5(.)] 439. <br /> ❑ 6.OTHEROENERATORFUFL [195.UNKNOWN 17 99.OTHER(Specify): Fuel Additive Mo <br /> CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED <br /> ❑ 3.DIESEL ❑ 5.LET FUEL ❑ &AVIATION GAS Mo. <br /> ❑ s.PETROLEUM 13LENDFUFr ® 9.OTHER PETROLEUM (specifft,LUBRIZOL 08BB Fuel Additive <br /> NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL <br /> 4196 <br /> 11.OTHER NON-PETROLEUM (Specify): <br /> IV. TANK CONSTRUCTION <br /> -- TYPEOF-TANK --0-1 SEJGLE-WALL-N-2.DO L-- l]-95-UNKNOWN- 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN C] 99. <br /> 99.OTHER Specify): <br /> ei M4, <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.F1BF,RGLASS. [I6.EXTERIORMEMBRANELATER ❑ 7.7ACKKIE 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN El 99.OTHER(SiSylnc445. <br /> OVERFILL PREVENTION E I.AUDIBLE&VISUAL ALARMS U 2.HALL FLOAT 3.FILL TUBESHUT-OFFVALVE 452. <br /> ❑ 4.TAN&MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 01.SINGLE-WALLED 02.DOUBLE-WALLED [199.OTHER 458 <br /> SYSTEM TYPE R 1.PRESSURE ❑,2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 25 CCR[2636. 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 8.FLEX®LE I0.Eu PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SpecW): 464, <br /> SECONDARY CONTAINMENT ❑ L STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0'.RIGID PLASTIC. 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ecify): 464. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I-STEEL N 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Specify) 4N° <br /> 4661 <br /> VENT SECONDARY CONTAINMENT 0 1.STEEL 2 4.FIBERGLASS 10:.RIGID PLASTIC 90.NONE 99.OTNER(Specify) 464f <br /> 46111 <br /> VRPRIMARYCONTAINME'NT Cl I.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ls'90..NONE 99.OTHER(Specify) 4648 <br /> 4"91 <br /> VR SECONDARY CONTAINMENT 1.STEED 4.FIBERGLASS 10,EGIDPLASTIC M 90-NONE 11 99.OTHER(Specify) 464 <br /> 464h1 <br /> VENT PIPIN43 TRANSITION SKIMP TYPE 1.SINGLE WALL 2.DOUBLEWALL 90.NONE 4MU. <br /> RISER PRIMARY CONTAINMENT wn 1.STEEL Lj 4.FIBERGLASS MU 10:RIGIDPLASTIC Ui 90.NONE U 99.OTHER(Specify) 4w1 <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT 1.STEEL • 4.FIBERGLASS I0.RIGIDPLASTIC 90.NONE Q 99.0'DBER(Specify) 4641 <br /> 4640 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STAIKERPLATE/BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451,-0 <br /> VII.UNDER DISPENSER CONTAINMENT WDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS E 90.NONE 469n <br /> CONSTRUCTION MATERIAL E3 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.0THER S 4 '0 <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 0 &ISOLATION ut <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, <br /> and In fall compliance wlt elm req ulrements. <br /> APPLICANT SIGNATURE / DATE 170. <br /> Ft^„' <br /> APPLICANT NAME(prmt) 471' APPLICANTTTTL,E 4n. <br /> David H Rogers Directs of Real Estate Oeveb meat <br />