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Age- s /-/67-9 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,R,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430` 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 103 CITY LOD I 104 2680 REYNOLDS RANCH PARKWAY H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 4 0 1.A STAND-ALONE TANK Containment Solutions ❑2.ONE INACOMPARTMENTEDUNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 1, 500 1 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ 1 b.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 09) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN N 99.OTHER(Specify): Fuel Additive 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL [16.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL N 9.OTHER PETROLEUM (Specify): LUBRIZOL 9886 Fuel Additive 440" NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION ❑ 1.SINGLE WALL 0 2.DOUBLE WALL 95.UNKNOWN 443 -----PRO&►ILY-CONTAINMENT-------- --1,STEEL -3.FIBERGLASS ----❑-b.-INTERNAL-BLADDER---- - ---_-_- ---- ----------- ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [] 99.OTHER (Specify): 4448 SECONDARY CONTAINMENT [11.STEEL 0 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 4458 OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT b 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 Q 99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION E23 CCR§2636(a)(3)) 4$3 PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464 PIPINGffURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL If 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 4640 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4613 464 1 VR SECONDARY CONTAINMENT 13 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE E3 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL Q 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS ❑ I0.RIGIDPLASTIC LI 90.NONE ❑ 99.OTHER(Spccify) 4641 464'1 RISER SECONDARYCONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 90.NONE [199.OTHER(Specify) 464k 464kI FILL COMPONENTS INSTALLED ELSPILLBUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS Q 10.RIGID PLASTIC ET99.-OTHER(Specify) 469b c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 443. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system Is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full com Bance with legal requirements. APPLICANT SIGNATURE,,,^':- DATE 470. APPLICANT NAME(print) 4n. APPLICANT TITLE 472. David H Rogers Director of Real Estate Development UPCF UST-13-1/2 Rev.(12/2887)