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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form pm UST) TYPE OF ACTION (Check one ilem only. For a USTclmure or removal,complete only the section and Sections L 11.ill.N,and lX below) ala. 11I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: ,O DATE EXISTING UST DISCOVERED: age. I. FACILITY INFORMATION FACILITY IDA(Agency Use Only) ...._ L BUSINESS NAME(Same as Facility Name or DBA-Do ft Business As) 3, Costco Wholesale gas station#658 BUSINESS SR'B ADDRESS 103. Croy la 3250 West Grantline Road Trac II. TANK DESCRIPTION TANK ID M 02. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS u4. Two Containment SOlaliam ® LA STAND-ALONE TANK Co�oav P9rb we 2,ONE INA COMPARTMENTED UNIT m .IeO me. DATE UST SYSTEM INSTALI6D O6. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 433. SePt 2002 20,000 0 III. TANK USE AND CONTENTS TANK USE ® Is.MOTOR VEHICLE FUEIPIG p Ib.MARINA FUELING pla AVIATION FUELM p 3.CHEMICAL PRODUCT STORAGE p xtl 00) p 4.HAZARDOUS WASTE(i.Um tlS.EMERGENCY GENERATOR FUEL Disc I232113(c)) --. -.._.__Q 6.OTHER GENERATOR FUEL _ ❑ 95.UNKNOWN p 99.OTHER(Spcily); 439a CONTIUvTS PETROLEUM: ® le.REGULAR UNLEADED ❑ I4.MIDGRADE UNLEADED p Ib.PREMIUM UNLEADED 449. p 3.DIESEL ❑ 5.JET FUEL p 6.AVIATION GAS ..___........_ p S.PETROLEUM BLEND FUEL C3 9.OTHER PETROLEUM(Speoiryp IIOe. .._....�- ._.._.._ . ....__.. t90Pr-PETROLEUM:�-].USED OIL fj 10.ETHANOL "- - 11.OTHER NOFN-PETROLEUM(Specify): 41pb. IV. TANK CONSTRUCTION TYPEOFTANK _ _-_- _ p LSINGLE WALL„_lt2 DOUBLE WALL O 93_UNKNOWN 40. PRIMARY CONTAINMENT p I.STEEL __.._. ® 3.FIBERGLASS p 6.INTERNAL BLADDER C) 7.STEEL+INTERNAL LINING O 95.UNKNOWN O 99.OTHER(Spcily): 444e SECONDARY CONTAINMENT _._._._,..-...-.__._...FI Q t.STEEL ....-__....._. .__. ®3.FIBERGLASS � 6.l0(TPJIIDR MEMBRANE LINER ❑ ].JACKETED M5. Cl 90.NONE p 95.LNKNOWN__ 099.OTHER(Ep6ciH):, 443A OVERFILL PREVENTION ® I.AUDIBLE M:VISUAL ALARMS 10 2.BALL FLOAT ❑ 3.FILL TUBE SNUmENVALVE 4.11 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVEN'ITON UIfw7M4df V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑„1,sfNGLE wAu .UOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ___. A..LPRESSURE p 2.GRAV[TY_......._..._13 1 CONVENTIONAL SUCTION...[3 4.SAFE SUCTWN RLgg7j2656W3)1 UA. PRIMARY CONTA24MENT p L STEEL p 4.FIBERGLASS ® S.FLEXIBLE ❑ la RIGIDPLASTIC X66. ❑ 90.NONE ❑ 95.UNKNOWN 13 99.OTHF1ti5Pee fl): SECONDARY CONTAINMENT ❑ L9TEEL ❑ 4.FIBERGLASS- - - ® B.FLEXIBLE ❑ 10.RIGID PLASTIC -� �---- _- ___._. __Q 90.,NONE.,, ❑ 95 UNKNOWN,.._..... p 99.OTHER(Specily): 460c PIPINGrIVRBINE CONTARJMFNT SUMP TYPE 0 1.SINGLE WALL 2 DOUBLE WALL E3 90.NONE 661d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PI$E PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT O 1.MEL N 4.FIBERGLASS p M RIGID PLASTIC p 90,NONE p 99.OTHER(Specify): 49r- a6kl. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ lo.RIGID PLASTK p 90.NONE ❑ 99.OTTIFA(Sp.. Nan VR PRIMARY CONTAINMENT p 1.STEEL ® 4.FIBERGLASS p 10.RIGID FlASTR. p 90 NONE p 99.MIIER(Sp 4): VR SECONDARY CONTAINMENT p L STEEL R 4.FIBERGLASS Cl 10.RIGID PLASTIC p 90.NONE p 99.OTHER(Spciry): 4 VENT PIPING TRANSITION SUMP TYPE - p_1.SINGLE WALL p 2.DOUBLE WALL- ® 90.NONE ---"- WL _..._- NI .__ _ RISER PRARY CONTAINMENT STEEL ® 4.FIBERGLASS [3IO.RIGID PLASM p 90.NONE p 99.OR(EA(Speeiryy. 46, ' RISER SECONDARY CONTAINMENT p I STEEL p 4.FIBERGLASS p 10.RIGID PLASTIC ® 90.NONE E3 99.OTIER(Speclry): 46eU_ FILL COMPONENTS INSTALLED -.... --1,SPILL BUCKET N 3.STRIKER PLATFAOTTOM PROTECTOR ...._...4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTADWENT aJDP CONSTRUCTION TYPE ® L SINGLE WAIS. p 2.DOUBLE WALL p I NODISPFNSERS p 90.NONE 669e CONSTRUCTION MATERIAL p 1 STEEL p 4.FIBERGLASS 0 to RIGID PLASTIC p 99.Omit(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PRCIFEC`ION E3 2.SACRIFICIAL ANOD 5 A IMPRESSED CURRENT 6.ISOLATION ESN• IX. APPLICANT SIGNATURE CERTIFICATION: 1 eertlry that this UST system Is campaHhk with the heardou,substance stored and that the lafermstion provided herahs is true, seessrsts,and In NB7%__ LLaaee wiN 1 al uirem6eu. 7 LI APPCANT SIGNATURE DATE 10/9/2009 4m. APPLICANT NAME(PrhR) Dcnnis Bock 411, 1 AppLjCANTTITLE Compliance Manager 41L UPCF UST-B Rev.(L2JZW)-U2 wwrr.RRWon.srR