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SIEMENS VAN IFIED PROGRANI CONSOLIDATED FIRM ),n UNDERGROUND STORAGE TANK ILC OPERATING PERMIT APPLICATION-TANK INFORMATION(One TomW per US 1) 'I YPF OF AC ZION (Chtrk one item only. For an I1ST penitnlcnt closure or removal.complctc only this section and Sections 1.It.Ill.IV.and IX bel(m 116 © 1.NEX I+L'RMrr ® 3.RI.NEWVAL PERMIT ❑ 5.CIIANGE OF INFORMATION G.Ti.MPORARY UST C•LOSURF. 0 7.LIST PERMANENT CLOSURE ON SITE 8.LIST REMOVAL DA TL LIST PF•.R?.ANEN"l LY CLOSED: LWra DATE.EXISTING LIST DISCOVERED: 1. FACILITY INFORMATION FACILITY If)a(.Igencc(:,c(bthv 1 B 1SINI=SS NAMF(Sana as FACILITY NAME or DBA-Doing Bti%aw,.As) Costco Gasoline IIIJSIN}:SS SITE ADDRESS 103 CITY ltlt If.TANK DESCRIPTION TANK ll) 13= TANK MANUFACTURER J)) TANK C•OATIGURATION: TIusTANKis Jit 2g Containment Solutions ®1.A ST.\ND-ALUSE TANK ❑2.ONE 1\A COMPARTMENTLU UNIT. jm"Im ('011allete oNw ruft fa each&m IJrullellt no IIIc 111111. DA'I1.1IS I SYS H'Al INSTALLED J35 TANK CAPACITY IN GALLONS JX+ NUMBER OF COMPARTMENTS IN THE I INIT 1?' 30.000 one(1) III.TANK USE AND CONTENTS 'TANK I ISE ® b MOTOR VF.IIICI t:FULLING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING Jt•, ❑ i CItF\IICAI.PRODVCT STORAGE ❑ 4.11A7_gRDOUS WVASTEIIncLules OedOif) ❑ 5 EMERGENCY GENMATOR FUF1.111si 24z*t o.yl ❑ 6 01III-K(JENLRA IOR I t'LI. ❑ t+t.l.:.NKNO11'K ❑ 99.OTHER (Sptci(). CCINTENTS PL IROI 1 I'\I ® la REGULAR I"NLLADED ❑ Ic.XIIDGRADE UNLEADED + ❑ Il+ PREMIUM L:NI.E.4D1:17 ren ❑ 3 DIES11 ❑ 5 JET F1'EL ❑ 6.AVLATION rAS ❑ S PETROL la:\1 BLEND FEEL ❑9.OTHER PETROLEUM S cik): +1'u NON•PL7 ROLIA TI.0 7 1"SED OIL 0 10.ETHANOL 11 OTIICR NON-Pl..rltC)Ll..0\I tS cifvl: JJa. IV. TANK CONSTRUCTION IYPF.Of TANK ❑ t SIMILE WW'ALL ® 2.DOUBLE WVALL ❑95.UNKNOU-N u? PRIMARY CONTAINNIFNI I SI ELL 0 3 1I111:R(AASS El 6INTERNAL BLADDER til ❑ 7.srLI:L+ INTERNAL LINING ❑ 95.UNKNOW\'- ❑ 7).OTHER tSpecih'J. nl.l tiF:('e)ND:\Kl'Ct)NT,VN\iFN l ❑ 1 Sl'EEI. ®3 FIBERGLASS ❑ 6.EXTERIOR MEMBRANE.LINER 7.J.41'KETEI3 1,15 ❑ -a) NONE ❑ 95 UNKNOWN ❑99.OT11ER(S ciNi: 115:1 OVERI ILL PRF.VEN1JON I AUDIBLE N VISUAL ALARMS IN 2.BALL FLOAT 0 3.FILL TUBE SHUT-OFF V.AI_VF 0z ❑ J.TANK MLETS REQUIIUINIENTS FOR E.`(EAIPTION FRU\1 OVERFILL PRENTNT10N EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SI.NGI-L-W\ALLE) 2.IN)1.'BLE-WW'ALLLI) E399.oTHER dol SYSTE\I TYPE ® 1 PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ J tiAFE SUC110N 1:3(J:R:2(.34ar3)l IS` PRI\IAkV CONTAIN\ILN'7 ❑ I S'fEEI. In •1.FIBERGLASS 0 8 FLEXIBLE 0 10.RIGID PLASTIC 1!.t ❑ 9U.NONE ❑ 95 UNKNOWN- ❑99.OTHER(S ifv): 4•J, SIA'ONDARY CON IAIN\IENI ❑ 1 STEEL t3) 4.FIBERGLASS ❑ 8 FLEXIBLE 10 RIGID PLASTIC Nltb ❑ 91).NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): PIPIN6.1 URIIIN1:VONI AMME.NT SUMP TYPE L SINGLE%%FALL 2.DOUBLE p'ALL ❑ )U.NONE. In 41 Vl.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION \'liN7 PRIMARY('ON 1AINMENI 1 STEEL W J.FIBERGLASS 10.RIGID PLAS"FIC 13 90.NONE 99.OTIIER(Speedy) J6J. JWeI VFNf SE('Y)NDARY CONTAINMENT I SI EEL M d.FIBERGLASS 10,RIGID PLASTIC 0 90.NONE 99.OTHER(Specirv) 14U I61(1 VR PRIMARY CON I AIN\IF.N7 1 STEEL. J FIBERGLASS 10.RIGID PLASTIC El 90.NONE 0 99.OTHER(SpeciA) 464p IWO VR SECONDARY CONI AINMI'Nl El I STEEL W 4 FIBERGLASS E3 10.RIGID PLASTIC 0 ,N).NONE E3 99.OTIIER(Sprci F•) Jdth 40,11,1 PIPING TRANSITION SUMP TYPI: 1 SINGLE WCALL 2.DOUBLE WVALI. 9u.NONE 164/ RISER PRIMARY CON fAINaiI.N f at I Sl FF.I U J.FIDERGLASs U 10.RIGID PLASTIC El 90 NONE El 99.OTHER(SpcctA 1 14q loh I RISER SECONDARY CONI AIN\IENT 0 1 STEEL J.FIBERGLASS 13 10.RIGID PLASTIC ® 90.NONE. 13 99 OTHER(Spccdj) I"k to ICI rig-COMPONENTS INS TALL11) 1.SPILL BUCKET Ca 3.STRIKER PLATE,wrrO\t PROTECTOR 4.CONTATNMENf SUMP 151x-: VII.UNDER DISPENSER CONTAINMENT(UDC) CONST RUCTION TYPI: ❑ I SINGLE WALL ® 2.DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90 NONE I094 CONSTRU CHO N\IATLKIAI. 0 1.S'1 F.Et. 0 d.FIBERGLASS 0 10.RIGID PLASTIC _"01 (SrccilO 0111., VIII. CORROSION PROTECTION STEEL CO\IW)NEN I'PK0TECTWN ❑ 2 SACRIIICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.IS01 1'f ION N/A I IX. APPLICANT SIGNATURE CER"riFi('AT'10\: I certify that this CS"I'system Is compatible with the hazardous substance stored and that the Information provided herein i%true.accurate. and In full compliance Wc}th legal requirements. qo APPLICANT SIGN:\"fllKl: D1 06/28/10 (_. APPLICANT NAN1L-(Imine) J'I APPLICANT TITLE e= Dennis Bock Environmental Compliance Manager 14573.009.pdt UPCF 1'ST-13-1/2 (Lev.(12/20117)