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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (0-formperusT) TYPE OF ACTION (Check one item only. For a USTclw re or removal,coBV*tr only this section and Sections All,111,1V and IXbelow) 430. ❑ 1.NEW PERMIT C4 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7,UST PERMANENT CLOSURE ON SITE n 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430e DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 4 BUSINESS NAME(Same as Facility Name or DBA-Doing Business T1s) Costco Wholesale W station#658 BUSINESS SITE ADDRESS 103, CITY 109 3250 W. Grand Ave. I Trac H. TANK DESCRIPTION TANK ID A 432• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 One Containment Solutions ® 1.A STAND-ALONE TANK c mplae oue Inge fm eech LONE IN A COMPARTMENTED UNIT mmpeftaww-1 wta. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS N THE UNIT 437 Sept.2002 20,000 0 III. TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(teeluda Used 09) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25:81.5(c)) _ [3 6.OTHER GENERATOR FUEL 0 9_5.UNKNOWN ____ _❑ 99.OTHER(Specify): 4391 CONTENTS PETROLEUM„ ® la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED a4o ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL---[39.OTHER PETROLEUM(Specify): 440a, NON-PETROLEUM: 7.USED OIL $-10.ETHANOL Cl 11.OTHER NON-PETROLEUM( 44% IV- TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL ® 2.DGUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL C5 3.FIBERGLASS ❑ 6.INTERNAL BLADDER --- - -'-444 _ ❑ 7.STEEL 4-INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER(Specify_): 444e. SECONDARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED -- 445 _- -- ❑ 90.NONE _ _❑ 95.UNKNOWN El 99.OTHER(Specify): 445.. OVERFILL PREVENTION e 0 1.AUDIBLE&VISUAL ALARMS N 2,BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE __.._._-ani 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL al.DOUBLE WALL ❑ 99.OIHER_ 460. SYSTEM TYPE R I.PRESSURE ❑ 2.GRAVITY _❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(s)(3)) 456. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spwify)-. 4ML SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PIASTIC 464G ❑ 90.NONE ❑ 95.UNKNOWN_ ❑ 99.OTHER(S i L_ 464a PIPINGITURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE -464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL..PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464a VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464n, VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [3 94-OTHER(Specify): VENT PIPING TRANSITION SUMP TYPE E31.SINGLE WALL [32.DOUBLE WALL ® 90.NONE -- --- . -- - TE+ - RISER PRIMARY CONTAINMENT 131.STEEL 0 4.FIBERGLASS [310.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Specify): RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464ki. FILL COMPONENTS INSTALLED 1,SPILL BUCKET---® 3_STRIKER PLATEIBOTTOM PROTECTOR --..)� 4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. CONSTRUCTION MATERIAL ❑ 1.STEEL Ia 4.FIBERGLASS ❑ 10.RIGID nASTTC ❑ 99.OTHER(Specify) 40 VIII. CORROSION PROTECTION STEEL.COMPONENT PROTECTION ❑ 2.SAMFICiAL ANODE(S) ❑ 4,IMPRESSED CURRENT Cg 6-ISOI A-MON 44N IX. APPLICANT SIGNATURE CERTMCATION: I cer"that this UST system is compatible with the hazardous substance stored anti that the information prodded herein is true, &= a"in fall compliance with[ al aireme"M APPLICANT SIGNATURE DATE 10/5/2009 470 APPLICANT NAME(Print) Dennis Bock 471 APPLICANT TITLE Compliance Manager 4712 UPCF UST-8 Rev.(12J?101117)-1/2 w4rw.nnitioce.org