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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ S.CHANGE OF INFORMATION 4w. <br /> (Cheek taw Iona only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITYCI.OSIIRE ❑ 9.TRANSFER E)RMIT�CIDSUTRE <br /> L FACILITY:INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILGY ID# <br /> 3lAgency Use Only,) <br /> BUSINESS NAME(s.mp tcnnv zsan�a neA-tzeae a,em_,t,7 t <br /> Costco Wholesale gas station#658 <br /> BUSINESS 51 IB ADDRESS CLTY iw <br /> 3250 West Grantline Road Trac <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2,FUEL DISTRMURON Is the facility located on Dian Reservation or Oar. <br /> 3.FARM 11 4.PROCESSOR r7l 6.OTHER Trust Imda7 ❑Yes ®No <br /> IL PROPERTV'.OWNER INFORMATION <br /> PROPERTY OWNER NAME go I PHONE ao . <br /> Costco Wholesale Corp. 425 313-8100 <br /> MAILING ADDRESS 409, <br /> 999 Lake Drive <br /> CITY eta 1 STATE art. ZtP CODE 4¢. <br /> I WA 98027 <br /> 44OPERATOR.INFORMATION. <br /> TANK OPERATOR NAME -- PHONE 41 2 <br /> Costco Wholesale Corp. Atm:Dentis Bock 425 427-7653 <br /> MAILING ADDRESS 412-1 <br /> 999 Lake Drive <br /> CITY • STATE 4244 ZIP CODE +zea <br /> Imquah WA 98027 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. 1 FHONB 4rs. <br /> Costco Wholesale Co 423 313.8100 <br /> MALLING ADDRESS 416. <br /> 999 Dake Dive <br /> CITY u7. STATE Ile. ZIP CODE 419. <br /> Inaguath WA 199027 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY �• <br /> ❑ 7.FEDERAL AGENCY 1@ &NON-GOVERNMENT <br /> V. BOA1W OF EQUALIZATION UST'STORAGE,FECCCOUNT NUMBER <br /> TY aX)HQ 44 / Cal the State BwN of Equalization,End Tu Division,if there are yucstiooa tet' <br /> VI.PERM HOLDER INFORMATION <br /> Issue perm t and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 10 4.TANK OPERATOR 42a <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> aa. <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Requved For Public Agencies ONy) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information proAded herein Is t un,accurate,and in full cons lance with legal requirements. <br /> APPLICANT 57GNANRE ^---0 DATE /� +z4. <br /> PHONE 4n. <br /> APPLICANT NAME(print) y 4M APPLICANTTITLE 4n <br /> Dennis Bock Compliance Mans ar <br /> UPCF UST-A Rev.(12/2007) <br />