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kL lu UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 N L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6,TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: iIO, 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 COSTCO GASOLINE LOC. NO. 1091 BUSINESS SITE ADDRESS l03 2680 REYNOLDS RANCH PARKWAY cr!`Y LODI 104 H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 431 TANK CONFIGURATION:THIS TANK IS 434 4 0 1.A STAND-ALONE TANK Containment SOZUtions ❑2.ONE INACOMPARTMENTED UNIT. Ce lele one emic for each co enment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 TBD 1, 500 1 M.TANK USE AND CONTENTS TANK USE ta.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ to.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inctudce 1J d oil) ❑ 5,EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ -6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ 1a,REGULARUNLF.ADED ❑ to.MWRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM (specify): LU13RIZOL440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑.1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT © 1.STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑99.OTHER (S ecifv: 444a SECONDARY CONTAINMENT -❑ 1.STEEL M 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90,NONE ❑ 95.UNKNOWN ❑99.OTHER(Specifo 445a OVERFILL PREVENTION E I.AUDIBLE&VISUAL ALARMS 0 2.BALL PLOAT i 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/'WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED . 0 2.DOUBLE-WALLED 0 99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2,GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(x)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL N 4.PIBEROLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONR [3,95.UNKNOWN. ❑ 99.OTHER(Speci ): 464 SECONDARY CONTAINMENT ❑ 1.STEEL a 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464f 464ft VR PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL E 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT El 1.STEEL 4,FIBERGLASS 10.RIGID PLASTIC 90.NONE U 99.OTHER(Specify) 46aj 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR E 4.CONTAINMENT SUMP 451&.c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑99.OTHER S cci ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE d � t� 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472. David H R ge Director of Real Estate Development UPCF UST-11-112 Rev,(12/2007)