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aA A <br /> 0 . <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> t <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One litrut per f:tcilky) <br /> TYPE OF ACTION ® 1.NEt4'1'LRMIT ❑ S.CIIAN(iE t)F INFORMATION ❑ 7.PEMIANENT FAC'tf.ITY CLO>t IRE Axt <br /> tt1aYkunc Ncm.nitrt ❑ 2,RI:NEWAI 11AMIT ❑ 6,TEMPORARY i:AC1LIlY CLOSURE ❑ 9.'i'RANSFI'R PiRAfl7 <br /> 1. FACILITY INFORMATION <br /> 'DOTAL NI'All1CR OF I ISI-%A C FAC'11.1'IY >,tt !'AClLITY ID a _ t <br /> 3 r.lD;ennt're(hurl <br /> BUSINESS NAMI.(&ww a.,ACWT V\A,\,t.u n►►.a-Haag nu,rue.,A,t n <br /> Costco Gasoline <br /> BUSINESS SI11:ADDRESS to)• CITY too. <br /> 322 East Hamey Lane Lodi <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.KIEL DISTRIBUTION X03' Is the facility lacaled on Indian Rcu"Won of M' <br /> 3.FARM 13 4.PRO F MOR Q 6.U1'HGR Trust sands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> I'ROPLRIY OUVNFR NAWI. to PHONE lots <br /> Costco Wholesale ( 425 ) 313-8100 <br /> M?irl.lNr,eDnRLSs <br /> 999 Lake Drive <br /> CIT ti' ata. STATE ►r, LZIPCODG U.Issaquah WA 27 <br /> 111. TANK OPERATOR INFORMATION <br /> TAMC OPERATOR NA.M +'+.l PHONE 4:a•_ <br /> Costco Wholesale 4 425 ) 313 8100 <br /> MAILING ADDRESS <br /> Le-3 <br /> 999 Lake Drive <br /> c'ITY '=8+ STATI! 42S.` ZIP CODE I , <br /> lssa uah WA 1-98027 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NANIt. tt+ PIIONf: ,ls. <br /> Costco Wholesale f 425 ) 313-8100 <br /> MAILING ADDRESS <br /> lora <br /> 999 Lake Drive <br /> CITY STATE o►s. ZIP CODE <br /> nA <br /> 1 uah WA 88027 <br /> OUTNER TYPE ❑ 4.LOCAL AGFNCY.T)ISTRIC'T ❑ S.COI INTY AOF.NCY ❑ 6.STATE AGENCY <br /> ❑ 7,I EDERAL AGENCY M S.NON.GO%UNNIENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO, 0 3 9 1 1 0 1 0 Cap the State Bawd of F.gaalization.Furl Tax M isum..if there are guestu+tt, t.r <br /> VI.PERMIT HOLDER INFORMATION <br /> Ivur penmi and cud legal n.xiiamtiona and mailings,tit: ❑ 1 FACILffY01VNFR <br /> ❑ 4.'I1NK +!i <br /> /N FRATt)It <br /> ® X TANK gWNER ❑ S.FACILITI.OPI:RA'IOR <br /> SUPFRVISOR OF DIVISION.SLC 110N.OR OFFtCF(Raxpnrcd For Public Agencies Only) xw <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certih that the information pniAded herein is trueaccurstand In full compliance with legal re ulrements. <br /> APPLICANT SIGNATURE DATE a=a PHONE +:! <br /> 34-� 06/28/10 425 313-8100 <br /> APPLICANT NA:dt1:(priali ,• APPLICANT TITLE it <br /> Dennis Bade Environmental Complititwo,Man er <br /> t'P('F t:ST Rrv.(12/2007) <br /> 14573.007.pdf <br /> L <br />