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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �pp <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION N 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF LISTS AT FACILITY 404, FACILITY ID# <br /> 3 (EXISTING) + 1 (PROPOSED)=4 (Agency Use Only) T <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> COSTCO GASOLINE (LOC. NO. 1091) <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2680 REYNOLDS RANCH PARKWAY LODI <br /> FACILITY TYPE N 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or a05. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ENo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> COSTCO WHOLESALE 425 313-6094 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 35005 <br /> CITY 410 STATE 411. ZIP CODE 412_ <br /> SEATTLE WA 98124-3405 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> COSTCO WHOLESALE (425 ) 313-6094 <br /> MAILING ADDRESS 428-3 <br /> P.O. BOX 35005 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> SEATTLE WA 98124-3405 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> COSTCO WHOLESALE (425 ) 313-6094 <br /> MAILING ADDRESS 416. <br /> P.O. BOX 35005 <br /> CITY SEATTLE WA 417. STATE als. ZIP CODE 98124-3405 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 13 1 g 1 1 0 1 0 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: . ].FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VIL APPLICANT SIGNATURE <br /> CER I ICATION: I certify that the'nformation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP I ANT SIG ATURE DATE 424. PHONE m<u Y 425, <br /> August 9, 2012 (425 ) 313-6094. <br /> APP CANT NAME(print) 426. APPLICANT TITLE 427 <br /> Gail E. Tsuboi Assistant Secretary <br /> UPCF UST-A Rev.(12/2007) <br />