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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Oneronumus-r) <br /> TYPE OTION (Check one item only. For a USTclwrme or remove(wmPlete only IhLS'ReU n and Secaow 1,11.111.!Y,and trbelow) 45e <br /> , <br /> ❑ !.NEW PERMIT3.REN`�EWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEITP ARY USTCLOSURE 7.UST PERMANENT CLOSURE ON Sfi'E S.UST REMOVAL <br /> DATE UST PFRMANENfLT CLOSET.. aSa. DATE E%ISTING UST DISCOVERED: 4Ka <br /> I. FACILITY INFORMATION <br /> FAcam ID a(egnxy u4e only) <br /> BUSINESS NAME(Same w PwW(Y Name or DBA-Doing gwlnest Aa) 3 <br /> Costco Wholesale station#658 <br /> BUSINESS SITE ADDRESS 103. 1 COY ,a <br /> 3250 West Gmntline Road Trac <br /> II. TANK DESCRIPTION <br /> TANK ID R 452. TANK MANUFACTURER u,. TANK CONFIGURATION:THIS TANK IS 4,4 <br /> TbI'fE Containment Solutions 01.ASTAND-ALONE TANK Covph*e amrpye Meeh <br /> 2.ONE <br /> IN COMPARTMENTED UN w mm eme uvi <br /> DATE SYSTEM INSTAL.IED c35. TANK CAPACm IN OAI_LCNS 4M. NUMBER OF COMPARTMENTS IN THE E 437. <br /> SCpL 2002 20,000 0 <br /> III. TANK USE AND CONTENTS <br /> TANKUSE 0 Ii MOTOR VEHICLE FUELING ❑ MMARINAFUELING - ❑ Ia AVIATION FUELING 410. <br /> Q 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(,rnu uw 00) ❑ S.EMERGENCY GENERATOR FUEL DISC W221.504 <br /> _ 0 6_OTHER_G_E_N_ERATORFUIEL ❑ 93,UNKNOWN _ 0.99,OTHFR(Spcily): VA. <br /> CONTENTS PEmOIEUM: ❑ is REGULAR UNLEADED 0 le MMORADE UNLEADED ® Ib.PREMIUM UNLEADED 44D. <br /> Q 3 DIESEL ❑ S JET FUEL ❑ 6.AVIATION GAS <br /> _13R PETROLEUM BLEND FUEL _.Q 9 OTHER PETROLEUM(Spceiry <br /> NOPF,MdEEIIM, 7 USED OIL 10 RTHANOL <br /> PL <br /> 11.OTHER NON-PETROLEUM(Specify): <br /> 4496. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK Q 1.SINGLE WALL 2 DOUBLE WALL ._ 95.UNKNOWN <br /> 0 _._ , 0 6..____. <br /> PRIMARY ® <br /> NRY CONTAINMENT O I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER <br /> __t7 7.STEEL,INTERNAL LIVING ❑ 95.UNKNOWN Q 99.OTHER(Spmiry): U4a <br /> SECONDARY CONTAINMENT - . .___ .....-0--6. <br /> ..._..- _ <br /> ❑ 1.STEEL ®3.F[BEROIASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,LOCKET® W. <br /> Q W.NONE ❑ 95.UNKNOWN _-0 99.OTHER(specify): N5a <br /> OVIiRFILL PREYENr10N ® I.AUDIBLE&VISUAL ALARMS ® 2BALL FLOAT Q 3.FILL TUBE SRl71'-0FF VALVE <br /> /.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION` <br /> PIPING CONSTRUCTION 0 1.SINGLE WALL ® 2 [XTUBL6 WAIL �99:OTHFJL _ - 46a <br /> SYSTEM TYPE ,......._� 1.PRESSURE ❑ 1 GRAVfIY ❑ 3.CONVENTIONAL SUCTION _<.SAFE SU[Y[oN(U tta(t676( 419. <br /> f PRIMARY CONTAINMENT Q L STEEL ❑ a FIBERGLASS - ® &PIPXiBLE Q 10.RIGID PLASTIC .�. <br /> .,,._.._._..-....._090.NONE (],.95:UNKNOWN �99_OTHERISpaAy): 4w� <br /> SECONDARY COMANMENT 0 I.STEEL Cl 4.FIBERGLASS 0 RFLEXIBLE 6 10.RIGID PLASTIC ^� <br /> _.__._.__�.90.NONE Q 95.UNKNOWN Q 99.OTEieR._iS e�cily)_ aw <br /> PIPING/IURBINE CONTAINMENT SUMP TYPE I.SINGLE WAIL 2.DOUBLE WALL Q 90.NONE 4 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 19 4 FIBERGLASS Q l0.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Specify): <br /> Sever <br /> VENT SECONDARY MNTANME'NT Q I.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE 0 99.OTHER(Spec*): Sµ0_ <br /> VR PRIMARY CONTAINMENT ..- ASS E]3 I-.._ _.._.. ._..__-_.__....._ <br /> _ ❑ 1.STEEL ® 4 FIBERGLASS 0.RIGID PLASTIC Q 90.NONE ❑ 99.OTIiPR(speNy): <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 10 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE Q 99 OTHER(SpmRy): <br /> VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL 0 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPOON: <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE Q 99.0THER(SpeeifO: <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET 0 3.STRIKER PLATFIBOTIOM PROTECTOR 0 4.CONTAINMENT SUMP 431. <br /> VII. UNDER DISPENSER CONTAINMENT <br /> CONSTRUCTION TYPE N 1.SINGLE WALL Q 2.DOUBLE WALL Q 3 NO DISPENSERS 0 90.NONE <br /> .... ..._...... ..... ___._ ._.. ..._...--- <br /> ., �. <br /> CONSTRUCTION MATERIAE. Q I.STEEL Q 4.FIBERGLASS 0 10.RIGID PLASTIC Q 99.OTHER(Sp W) <br /> VIEY CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANOD 5 4.IMPRESSED CURRENT C9 S.ISOLATION 441. <br /> I.X. APPLICANT SIGNATURE <br /> CLRTMCATION:I certify that this UST syalam is compatible with the hazardous eabefance dared end that the Information Prodded herein L Irma, <br /> accurate,emd In fall m nw with laged reguLreaments. <br /> APPLICANTSIGNATURE DATE 10/9/2009 <br /> APPLICANT NAME(11121) Dennis BOCK •,,. APPUCANTTITLE Compliance Manager 4R <br /> UPCFUSI-8P .(tVM7)-IR www.omidoa4,rR <br />