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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per DST) W1. E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,Ill,IV,and IX below)E4" NEW PERMIT ® J.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ C TEMPORARY USP CLOSURE 7.UST PERMANENT CLOSURE ON SITE 9.UST REMOVAL DATE UST PERMANENnY CLOSED: as DATE EXISTING UST DISCOVERED: 4361 L FACIIITY INFORMATION FACHM ID)7(Agency Use only) _ I BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Business As) ) COSTCO GASOLINE (LOC. NO. 1091 BUSINE SSITE ADDRESS "n CITY IN 260 REYNOLDS RANCH PARKWAY LODI IL TANK DESCRIPTION TANK ID g TANK MANUFACTURER 03 TANK CoNFIGuRAnoN:T)nS TANK Ts Tt+ 4 NLASTAND-ALONETANK �( D Containment Solutions ❑2.ONE M A COMPARTMENTED UNIT. le ane rareacac ,s in Ne rk. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 4R NUMBER OF COMPARTMENTS IN THE UNIT 411 TBD 1 500 1 M.TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLEFURLING ❑ Ib.MARINA FUELING ❑ Ic.AVIATIONFUELING 09 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Izl Uud01) ❑ 5.EMERGENCY GENERATOR FUEL BMK!Sn2a1.f(.B ❑ 6.OTHER GENERATOR FUEL. ❑ 95.UNKNOWN ❑99.OTHER(S «' ): 4391 CONTENTS PETROLEUM: ❑ Ia,REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ IA PREMIUM UNLEADED 441 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM (3 4101 NON-PETROLEM-❑ 7.USED OIL E3 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify); 4491 IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL 0 2.DOUBLE WALT. 095.UNKNOWN W PRIMARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS U 6.INTERTIAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER 44b SECONDARY CONTAINMENT 0 1.STEEL N 3.FIBEROLASS ❑ 6.E(TERIORMEMBRANELINER 7.JACKBTED 445 90.NONE ❑ 95.UNKNOWN 99.OTIlER S -!'Ili 4454 OVERFILL PREVENTION I.AUDIBLE&VISUALALARMS 2.BALL FLOAT 3.FIL TUBB SHMTOPF VALVE OL 4.TANK MEETS RHQUIREMENIS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINOLE-WALLED 2.DOUBLE-WALLED 99.OTHER 449 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.S SUCCION CCR q1 PRIMARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS ❑ S.FLEXIBLE U 10.RIGID PLASTIC IN ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0THER(S I ): 464a SECONDARYCONTATNMENT ❑ 1.STEEL 0 4.FIBERGLASS LI S.FLEXIBLE ❑ 10.RIOID PLASTIC 466 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 444 PIPINGrTURBINE CONTAINMENT SUMP TYPE ❑ I.SLNOLR WALL 0 2.DOUBLE WALL tj 90.NONE 4141 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL E 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.DIFFER(Specify) 46N 46h1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4Nf 464A VA PRIMARY CONTAINMENT L.STEM. 0 4.P-MERGLASS I0.RIGTD PLASTIC E 90.NONE 99.OTHER(Specily) 464 46411 VR SECONDARY CONTAINMENT ❑ L.STEEL 0 4.FIBERGLASS IO.RIGIDPLASTIC a 90.NONE 99.OTHER(Spacify) 4641 464et VENT PIPING TRANSITION SUMP TYPE El I.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE 46/i RISER PRIMARY CONTAINMENT LJ 1.STEEL E 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.O HER(Specify) 464J 4641 RISER SECONDARY CONTAINMENT 1.STEEL E 4.FIBERGLASS E3 t0.RIGID PLASTIC 0 9o.NONB 99.OTHER(Specify) 46% 46441 FILL COMPONENTS INSTALLED N I.SPILLBUCKBT S.STRIKBRPWTEIBOn-OMPROTECTOR E4.CONTAINMSXTSUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL O 2.DOUBLE WALL ❑ 3.NO DISPENSERS E 90.NONE 449• CONSTRUCTION MATERIAL 0 1.STEEL ❑ 4.FIBERGLASS 0 10.RIOID PLASTIC 0 99.OTHER(Specify) 469be VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICLALANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION Ne. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Is eampaEbk with the huardeus substance stored and that the Information provided heroin h true,aceunte, and In full tompliarce with legal re riremsots. APPLICANT SIGNATURE IrM&A DATE 478, q l2 APPLICANT NAME(print) 471' APPLICANT B 471, David H R e Director of Real Estate Development UPCF UST-B-112 Rev.(12/1007)