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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> lune turn,per facility) <br /> TYPE OF ACI ION ® I.NEWPLRMII ❑ 5.CHANGE OF INFORMATION ❑ 7.PERIIIANENT FACILITY CLOS(IRI: 1c"' <br /> Whcdmw arm on)cl ❑ 1.RENFWAI PLRhtIT ❑ 6. 1ESIPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION �S <br /> 'I OTAL NI'MRI-.R OF US I's A F FACILITY JOJ FACILITY ID,,,, <br /> 3 r:I,t:ency f.'cc•On/. pZ D <br /> IWSINESS NAiSH.(S:n1K:n 1 A(11.11Y NA\II.u DDA-rani,Dminc,A.1 <br /> Costco Gasoline <br /> BUSINESS SITE ADDRESS ((,? CITY IuJ <br /> 322 East Haney Lane Lodi <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.1 IJEL DISTRIBLIT)ON 401. Is the facility located on Indian Resrrtation o1 10 <br /> 3.FARM 4.PROCESSOR 6.OTHI R Trust lands^ ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPER]Y(A NER NAME. X07 PHONE WS <br /> Costco Wholesale ( 425 ) 313-8100 <br /> !MAILING ADDRESS 409 <br /> 999 Lake Drive <br /> CITY 110 STATE J11 ZIP COI) 112 <br /> Issaquah I WA 98027 <br /> III. TANK OPERATOR INFORMATION <br /> G1NK OPFRA fOR NASIL 77( <br /> NE <br /> Costco Wholesale 25 ) 313-8100 <br /> MAIL.IN(i ADDRESS t_s•? <br /> 999 Lake Drive <br /> Cl fy J2`' STATE -126-5 1 ZIP CODE <br /> Issaquah WA 98027 <br /> IV. TANK OWNER INFORMATION <br /> TANK f)WNIat NA411. n 1 PHONE n s. <br /> Costco Wholesale 7 425 ) 313-8100 <br /> N•IAILING ADDRESS ala <br /> 999 Lake Drive <br /> CITY 117. STATE 798027 <br /> IP CODE 114 <br /> Issaquah WA <br /> OW1ER TYPEi: ❑ 4.LOCAL AGENCY/DISTRicr ❑ 5.COUNTY AGFNCY ❑ 6.STATE AGENCY Q1, <br /> ❑ 7.F EDFRAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Tl'(TK)HQ 44- 1 1) 1 3 1 9 1 1 1 0 0 Call the State Board of Eclualiration.Fuel Tax Division.if there art quc%tion, 71 <br /> VI. PER1vIIT HOLDER INFORMATION <br /> lsuc Pernut:n)d send legal notifications and mailings a,: DI.FACILITY OWNER ❑ 4.TANK OPERA]OR 12• <br /> ® i.TANK OWNER ❑ 5.FACILITY om.*R:xTOR <br /> SUPERVISOR OF DIVISION.SEC FION.OR OFFICE(Required For Public Agencies Only) JW, <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information proAded herein is true accurate,and in full compliance with le al re uirements. <br /> APPLICANT SIGNATuRIi DATE -1-'4. PFIONE 12` <br /> 06/28/101 ( 425 ) 313-8100 <br /> APPLICANT NAME(print) APPLICANT TITLE 127 <br /> Dennis Bock Environmental Compliance Manager <br /> t'PC'F I:ST-A Rev.(12/2007) 14573.007.pdf <br />