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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (On form pa UST) TYPE OF ACTION (Check one teem only. For a USTcfwwe or removal,complete only this section and Sections 1,A UI,IV,and LYbelow) 430, Q 1.NEW PERMIT 3RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6,TEMPORARY UST CLOSURE 7..UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CIDSED. < DATE EXISTING UST DISCOVERED Owe_ I. FACILITY INFORMATION FACILITY ID q(Agency Use Only) BUSINESS NAME(Same as FadGry Name or DBA-Doing Ba W&$As) Costco Wholesale gas station#658 BUSINESS SITE ADDRESS 103 1 Cryy 1a. 3250 West Grantline Road Trac H. TANK DESCRIPTION TANK ID H an TANK MANUFACTURER 43 TANK CONFIGURATION:THIS TANK IS 04. One Containment Solutions ® 1.A STAND-ALONE TANK Canpla9oeePeW m a 0 DATE UST SYSTEM WSTALIED 4JS. 2.ONEINA COMPARTMENTRDUN1f 4aaeeR TANK CAPACFTY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 431, Se L 2002 20,000 0 III. TANK USE AND CONTENTS TANK USE 0 In MOTOR VEHICLE FUELING Q Ih.MARINA FUELING ❑ IC AVIATION FUELING 'LF? C3 ICKMMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6uhtla Ua 0.0 13 s.EMERGENCYGMaRATOR FUEL(BBC inni.1(c)1 06.OTHER GENERATOR FUEL I7.-95.UNKNOWN Q 99.0T118t(SpenAy),. 439& CONTENTS PETROLEUM: 0 IL REGULAR UNLEADED -- 13 1e.MIDGRADEIINLEADED O Ib.PREMIUM UNLEADED 440. 0 3.DIESEL 0 5.LET KIEL 13 6.AVIATION GAS 13 R PETROLEUM BLEND FUEL 0 9,OTHER PETROLEUM(Specify): 4toa NON-PETROLEUM: 7.USED Oa � I0.Rn1ANOL 11 1LOTHERNON-PETROLEUMS i : 4400. IV. TANK CONSTRUCTION TYPE OF TANK Q 1.SMOLEWALL..02,.DOUBLE WALL__ 9s.UNKNOWN. .. W. PRIMARY CONTAINMENT 13 1.STEEL M 3.FIBERGLASS 13 6.INTERNAL BLADDER 441 ___..._. ___._....❑--7.STEL.+INTERNAL LINING 93.UNKNOWN Q, 99.OTFTFR(Speaft 444•_____ SECONDARY CONTAINMENT 13 1.STEEL ®3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER Q 7.JACKETED 4e. _ _ 0 9o.NONE 13 95.UNKNOWN Q 99.OTHER(Spec(%); ass OVERFILEPREVEN'HON-- ®L AUDIBLE&VISUAL ALARMS ---® 2.BAIL FLOAT -_ - �13 3.FILL TUBE SHUT-OFF VALVE -- ------752 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE,PIPING CONSTRUCTION PIPING CONSTRUCTION_ _ 13 LS OLE WALL jj 2 DggkE WALL _�99_07RER „__ 44^ SYSTEM TYPE 0 I.PRESSURE ❑ 2.GRAV1IY �,3_CONVENTIONAL SUCTION,Q 6 SAFE SUCTIONJ2s OCR Q3636p7(�]___.45r. PRIMARY CONTAINMENT 13 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE 13 10.RIGID PLASTIC 46+ 13 90.NONE .--.0 95.UNKNOWN .._. E3 99.OTHER(Sped%1: ,64a SECONDARY CONTAINMENT Q 1.STEEL 0 4.FIBERGLASS ® 8.FLEXIBLE 13 10.RIGID PLASTIC 4640 .._ -.- -- 1390.NONE_.....----....---._O9s.uNKNowN ..,..-,E_99.OTHER(Speci%): '6'c PLPINORURBINE CONTAINMENT$UMP TYPE I.SINGLE WALL 2.IGNITE WAIL 90.NONE 464a VI. VENT,VAPOR RECOVERY(VR)AND RISER[FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 13 4.FIBERGLASS ❑ 10.RIGID PLASTIC 13 90.NONE 13 99.OTHER(Specify): µy1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS Q 10.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Sped%): VR PRIMARY CONTAINMENT Q 1.STEEL M 4,FIBERGLASS 13 10.RIGIDPLASTIC 13 90.NONE O 99.OTHER(Spedy): VR SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS Qyo.RiGiDnASHC 090.NONE 0 99.OIHER(spocft VENT PIPING TRANSITION SUMP TYPE 13 I.SINGLE WAIL 13 2.DOUBLE WALL 0 90.NONE RISER PRIMARY CONTAINMENT [3I.STERL ® 4.FIBERGLAS$ O 10.RIGID PLASTIC O 90.NONE 13 99.OTHER(Spmily): RISER SECONDARY CONTAINMENT O 1.STEEL 0 4.FIBERGLASS 13 10.RIGID PLASTIC ® 90.NONE 13 99.OTHER(Sped%): µo1. FELL COMPONENTS INSTALLED 1.SPILL.BUCKET' 3.STRIKER PIATEHOTI(3M PROTECTOR 8 /.CONTAMMENf'SUMP 451. VII. UNDER DISPENSER CONTAINMENT(UDC CONSTRUCTION TYPE ® 1.SINGLE WALL Q 2.DOUBLE WALL Q 3.NO D6SPENSERS C3 90_NONE 4691 CONSTRUCTION MATERIAL Q 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC Q 99.OTHER(Sped%) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE(S)[3 4.IMPRESSED CURRENT M 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I ceMy that this UST system if compatible with the barardear abstanee,tared anal that the inforemeen ptoAded herds M Less, and M fall cam Ranee with 1 r ■ emeetL APPLICANT SIGNATURE DATE 10/9/2009 4" APPLICANT NAME(prim) Dennis Bock a. APPLICANT TILE ComplianCe Manager 4n. UPCP UST-B Rev.(I2t200T)-I/2 MnNW.1ltNbes,ar{