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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE Of ACTION (Check one item onlx For a UST closure or removal,comPleIe only this section and Sections I,If,Ill,!Y,and LY below} M ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT © S.CHANGE OF INFORMATION 6.TEMPORARY UST CEASURE0 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CEASED; 430L I DATE E7{15TING UST DISCOVERED: a36b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) Costco Wholesale gas station#658 BUSINESS SITE ADDRESS 103. CITY la. 3250 W. Grand Ave, Trac II. TANK DESCRIPTION TANK[p# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Three COntainment Solutions C3 1,ASTAND-ALONE TANK compi4te one page for each 2.ONE INA COMPARTMENTED UNIT idftw* DATE UST SYSTEM INSTALLED 433. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT' 437 Sept.2002 20,000 a M. TANK USE AND CONTENTS TANK USE ® la MOTOR VEHICLE FUELING ❑ 1b.MARSHA FUELING ❑ lc.AVIATION FUELING 439, [33.CHEMICAL PRODUCT'STORAGE E34.HAZARDOUS WASTE(I.I dw U.A Oil) ❑ 5.EMERGENCY GENERATOR FUEL[NSC 1252[I.5(cN _❑ b,OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439L CONTENTS PETROLEUM: ❑ I a REGULAR UNLEADED (] la.MIDGRADE lTNL1ADED_- 01 b.PREMIUM UNLEADED440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Speei ): 44pr NON-PE kddUM: 7.USED OIL - 10.ETHANOL I L OTH£R NON-PETROLEUM "M. IV. TANK CONSTRUCTION TYPE OF TANK _ ❑ I.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT- ❑ L STEEL a 3.FIBERGLASS ❑ b.INTERNAL BLADDER ----- � 444. ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4"L SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ tr.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99,OTHER( fy): 445L OVERFILL PREVENTION"- 10 I.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FEL TUBE SHUT-OFF VALVE 4J2 C TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [ _4.SAFE SUCTION 123 CCR f2636(sX3)I 459. PRIMARYCONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIRERGLASS- ® 8.FLIXIBL.E ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SLmi ): 464C PIPING?TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY_CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify): JZ VENT SECONDARY CONTAINMENT ❑ 1,STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Spscify)t 4 116 VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE_❑ 99.OTHER(Specify): 4q VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4,FIBERGLASS ❑ I&RIGID PLASTIC © 90.NONE ❑ 99.OTHER(specify): 464(1. VENT PIPING TRANSITION SUMP TYPED 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE RISER PRIMARY CONTAINMENT ❑ I.S= 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46411. FILL COMPONENTS INSTALLED a I.SPILL BUCKET ® 3.STRIKER PLATEIROTTOM PROTECTOR Is 4,CONTAINMETTT SUMP +� VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE [3 1.SL14GLE WALL 1@ 2.DOUBLE WALL D_3 NO DISPENSERS ❑ 4Q NONE 469L CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC I,] 99.OTHER(Specify) �469b 369c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIALANODE(S) [3 4.IMPRESSED CURRENT 6.ISOLATION 14E. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this USC system Is compatible with the hazardous substance stored and that the information pro--ided herein is true. accurst sad In full compliance with le&A EMirementi. APPLICANT SIGNATUREDATE 1/5/2009 a?r. APPLICANT NAME(print) Dennis Bock 4FI' I APPLICANTTTFL.E Compliance Manager 412. UPCF GST-B Rev.(12/2007)-112 www.unidors.org.