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tJNIF1ED PROGRAM CONSOLIDATED FURriI UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fon» er11S'11 TYPE OF ACTION (C'hcck one ileo onl)'. For an I IST pen anew closure or removal.complete only this section and Sections 1.Ll,Ill.IV.and I\be6w) I% Q 1.NEW PERMIT ® 3.RENEWAL 11ERAiI1' ❑ 5.CIIANGF OF INFORMATION 6.1EMPORARY UST CLOSURE. 0 7,LIST 11LRIMANL•NT CLOSURE ON SITE: R.LIST REMOVAL DATE.(1ST PFR4IANI:N'11.1'C[.OSGL)• 1iC° DATE EXISTING UST UISCOVERF.D: 1. FACILITY INFORMATION FACILITY ID a(.lgcnl i'1*.%(btfrl Ill1StNESS NAME(Same as FACILITY NAME or DHA-Doing Business As) J Costco Gasoline BUSINESS SI FE:\DURESS 103 CFfY utl II.TANK DESCRIPTION TANK ID c 432 TANK MANUFACTURER 433 TANKCONFIGMATION: Tius TANKIS 2/31 ®I.A STAND-ALONE TANK 3 Containment Solutions ❑2.CINE IN AC OMPARTMF.NTED"NIT. Cat lete wIc use for tach coni n+t)asvt 1 Ntt mut. D:1'11:UST CYST .\1 INSTALLED 135 TANK CAPACI II'IN GALLONS IK NUMBER OF COMPARTMENTS IN THE UNIT I� 30,000 one(1) III.TANK USE AND CONTENTS 'IANKTISE 13 la.\IUTOR\'Eltl(-LFFI:kLING ❑ IRAIARINAFUELING ❑ Ic_AVIATION FUELIN(i 111 ❑ 1 ('Ht:hl1('AL PRODI CT STORAGE ❑ a.HAZARDOUS WASTE(Indtt•ie.Used Oil) ❑ 5.EMERGENCY GENERATCIR FI'LI plu'q24-`>;I°•r)1 ❑ 6.OI IIt!R f;fNER:ITOR FUhl. ❑ 95.UNKNOWN ❑ 99 OTHER (S cih•1: CONTENTS PETRI)I.FI \I- ❑ la.REGULAR UNLEADED ❑ Ic.\IIDGRADEl'NI.EADED ® Ib.PREMII:\Il1NLFADF.D aP) ❑ 3 DII:SF1 ❑ 5.JET FUEL ❑ 6 A\7A PION(;A3 ❑ S PF I ROLEUNI BLEND FU L (3 9.OTHL•R PETROLEUM islvcifv): 4.11t, NON-ft I ❑ 7 1'SFDOIL 0 l0 ETHANOL ❑ 11 (31 HER NON-PETROI_EUNI(S ifv): uta. IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 0 1 DOURI.F.W.U.I. ❑ 95.L-NKNOIVN 44: PRIMARY CONTAIN\IEN'I I Sl'FF.I. M 3 FIBERGLASS 6 INTERNAL BLADDER J)) ❑ ' STLEI.t INTERNAL LIKING ❑ 95.UNKNOWN ❑ 99 OTHER (S tidy j: )ua SECONDARY C'ONTAINMI-N ' 1 SI'EEL ®3 FIBERGLASS 6 EXTERIOR MEMBR.ANC LLNER 7.)ACKFTFI) us ❑ 90 NONE ❑ 9S.I;NKNO%%-N 1399.OTHER(S iNyl: 1.ISa U\'LRL ILI.PRL•VEN ION I AUDIBU&VISI AL.ALARMS 2 BALL FLOAT0 3.FILL'TI)BE SHUT-OFF\'AL\'1: ❑ a '1 ANK MEETS REQ(AREMEN'Ib FOR F..XFbIPI ION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION Pll'1Nti CONSIRU('T[1)N ❑1.SINGI.F-WALLED 102 DOI!BI.F-\VAI.L.ED ❑99.OTHER It'll 5YS1 ENi TYPh ® 1 PRESSURE. ❑ 2.GR.A.VI 'Y ❑ 3.CONVENTIONAL SUCI ION ❑ a.SAFE St:("HIEN 1.31 cK,:a3nan sl I'x PRIMARY CONTAINMENT ❑ 1 S"rl:EL 13 a•FIBF.RULASS 0 S.FLEXIBLE ICI.RIGID PLASTIC 161 ❑ 90.NUKE ❑ 93.C'NKNON\N ❑ 99 OTHERS iR,): 114, SECONDARY CONIA1N\IF.N1 0 I.STEEL M a.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 11.11. ❑ tN) NONE ❑ 95.1.1KN011N ❑ 99.OTHER(Specify): It..k. PIPING TURBINE CONTAIN\IE•NT SC\I['TVI'E L SrNGLE•WALL 10 2.DOUBLE WALL 0 90.NONE 141.1 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY C'ONTAMMENI E3 I STEEI. .1.FIBF:RG1 ASS 10.RIGID PLASTIC 0 W.NONE D 99.OTHER(Specif%1 461,• N.IrI VF.\`f SECONDARY CCINIAIN\ILNT 0 1 STEEL M a.FIBERGLASS 0 10 RIGID PI.\STIC 0 90.NONE 91).OTHER(Slx:61 1 I'Ar li.I(I \'R PRIMARY C'ONIAINNIENT 1 STFFL M 1.FIBERGLASS 13 10.RIGID PLASTIC 9o.NONE ❑ 99.OTHER(SrwiF9 lel: I:•tll YK SECONDARY 0ONIAINMEN1 1 STEEI. 50 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NONE E3 99.01HER(Specth-1 Ib IL I VEN1 PIPING I'kANSITION KI'>1PTVPE Q 1 SINGLE'WALL IM 2.DOUBLE WALL E3 'w.NONE 1,41 RIST.R PRIMARY C'UNtA1NMENI I@ I STEEI. Lj a 1'IBERGLASS U 10.RIGID PLASTIC LI 90.NONE D 99 0111FR(SIved'1 I .11.11 IoAI RISLR SECONDARY CONI AIN\IT T I STEEL J FIBERGLASS 10,RIGID PLASTIC EM 90.NONE Ej 99 OTI IER tSpccthy 11:1L 4611.1 FILL COMPONENTS INS\ALLED I SPILL BUCKET 3.STRIKER PLATE BOTTOM PROTECTOR M a.CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION'11'11 ❑ 1.SIVCiLE tv%LI. 10 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ tw.NOMI: �n9a CONSTRUC I ION MATERLAI_ I.S1 EEL 00 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(S cifv) VIII. CORROSION PROTECTION STEELC'OMP(�NF.NI PROTECr14N ❑ 2.SACRIFICIAL ANODE(%) ❑ a.IMPRESSEDCURRENI ❑ 6.ISOLATION N/A 1I' IX. APPLICANT SIGNATURE (ER'ITFIC'AT'ION: I certify that this L'SF system Is compatible with the hazardous substance stared and that the inrortuation provided herein is true.accurate. and in full compliance with legal requirements. APPLICANT SIGNATURE 1 DATE 06/28/10 APPLIC'ANl NAME(print) J71 APPLICANT TITLE 1' Dennis Bock Environmental Compliance Manager 14573.010.pdt lT('F UST-111 1/2 Rev.(12/21107)