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�.. & <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMrr ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) 0 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL.NUMBER OF USTs AT FACILITY sca <br /> FACILITY ID i€ � <br /> 3 (Agency Use Only <br /> BUSINESS NAME(5a m FACILrrY NAME or DRA-thing Business As) 3. <br /> Costco Wholesale gas station#658 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> .3250 West Grant Road Trac <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING #4' 405. <br /> ® ❑ 2.FUEL DISTRIBUTION is the facility located on Indian Reservation or <br /> 3.FARM 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes 0 No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4C7, PHONE 4as. <br /> Costco Wholesale Corp. 425 313-8100 <br /> MAILING ADDRESS 409. <br /> 999 Lake Drive <br /> CITY ata JSTATE 411. ZIP CODE 412. <br /> Issaquah WA 98027 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4.'8 s. PHONE 428.2 <br /> Costco Wholesale Corp- Attn:Dennis Bock (425) 427-7653 <br /> MAILING ADDRESS 428-3 <br /> 999 lake Drive <br /> CITY 424.4 STATE 428-5 ZIP CODE 4286 <br /> Issaquah I WA 198027 <br /> IV. TANK OWNER INFORMATION <br /> TANK OANER NAME 414 PHONE 415 <br /> Costco Wholesale Corp. (425) 313-8100 <br /> MAILING ADDRESS 418 <br /> 999 Lake Drive <br /> CITY 411 STATE 418. ZIP CODE 414 <br /> Issaquah WA 98027 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 430. <br /> El 7.FEDERAL AGENCY 0 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST'STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 Call the State Board of Equaliztion,Fuel Tax Division,ifthere are questions. 42t. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to- ❑ I.FACILITY OWNER 4.TANK OPERATOR 4D <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cer-lify that the information proviged therein is true accurate and In full com liauce with legal requirements. <br /> APPLICANT SIGNATURE DATF 424. 1 PHONE 425. <br /> 10/5/2009 (425)427-7653 <br /> APPLICANT NAME(peva) 446 APPLICANT TITLE 427 <br /> Dennis Bock Compliance Manager <br /> UPCF LIST-A Rev.(1212007) <br />