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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �pp <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION KX glMf�lli <br /> (One form per facility) <br /> TYPE OF ACTION E I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 40,1 FACILITY ID kI- <br /> 3 (EXISTING) + 1 (PROPOSED)=4 (ggency Use Only) <br /> BUSINESS NAME(Same u FACILITY NAME or DBA—noinS Business Au 3 <br /> COSTCO GASOLINE (LOC. NO. 1091) <br /> BUSINESS SITE ADDRESS 103. CITY IN <br /> 2680 REYNOLDS RANCH PARKWAY LODI <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands'? ❑Yes ENo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> COSTCO WHOLESALE 425 313-6094 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 35005 <br /> CITY 410 STATE 411, ZIPCODE 412. <br /> SEATTLE WA 98124-3405 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1- PHONE 428-2 <br /> COSTCO WHOLESALE (425 ) 313-6094 <br /> MAILING ADDRESS 428-3 <br /> P.O. BOX 35005 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> SEATTLE WA 98124-3405 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> COSTCO WHOLESALE (425 ) 313-6094 <br /> MAILING ADDRESS 416- <br /> P.O. BOX 35005 <br /> CITY SEATTLE 417. WA STATE 418. ZIP CODE 98124-3405 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> El 7.FEDERAL AGENCY E 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 3 1 9 1 1 0 1 O 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: . I.FACILITY OWNER E] 4.TANK OPERATOR 23 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certi that the'nformation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP ANT SIG TURFDATE 41-4 PHONE 425 <br /> August 9, 2012 425 313-6094 <br /> CAP CANT NAME(print) 426 APPLICANT TITLE 427 <br /> Gail E. Tsuboi Assistant Secretary <br /> UPCF UST-A Rev.(12/2007) <br />