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5 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION One form p,UST)�� TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,Til,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT N 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oaDATE 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) BUS 2680 I REYNOLDS RANCH PARKWAY Io3 CITY LOD I 104 H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:Tial$TAMC LS 434 4 0 1.A STAND-ALONE TANK Containment Solutions ❑2.ONE INACOMPARTMENTED UNIT. Complete one Pago for each compartment in the unit. DATE UST SYSTEM INSTALLED 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 TED 1 500 1 III.TANK USE AND CONTENTS TANK USE ❑ 1a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchdcs Used Oa) ❑ S.EMERGENCY GENERATOR FUEL INSC 125281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 9S.UNKNOWN 99.OTHER(Specify): Fuel Additive 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.]ET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM (Specify):LUBRIZOL 9888 Fuel Additive 440a NON-PETROLEUM:13 7.USED OIL ❑ 10.ETHANE.. ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPS OF TANK 0 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 40 PRI34ARYCONTAIIIIAEN3' -I.-STEEL __-_.. 3.FIBERGLASS ❑_6.INTERNAL-BLADDER .- -------- - --...__-- 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 44U SECONDAXY CONTA00AMM E3 1.STEEL 3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 913.11itlliriE ❑ 95.UNKNOWN [199.OTHER(Si : 4458 OVERIML .AUDIBLE&VISUAL ALARMS Ll 2.BALL FLOAT Ll 3.FILL TUBE SHUT-OFF VALVE 432- 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE-WALLED 0 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY El 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 2636 a 458 PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 0 S.FLEXIBLE ❑ 10.RIGID PLASTIC 164 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER( ify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE [}95.UNKNOWN ❑ 99.OTHER(Specify): 464e PIPINGI TURBINE CONTAINMENT SUMP TYPE jj L SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4640 464et VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE 0 99.OTHER(Specify) 464s 464 1 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464h 464ht VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC Ll 90.NONE U 99.OTHER(Specify) 464I 464'1 RISER SECONDARY CONTAINMENT 1.STEEL N 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE [199.OTHER(Specify) 464E 4641 FILL COMPONENTS INSTALLED MI.SPJLLBUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR E 4.CONTAINMENT SUMP 451a-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 ff 10.RIGID PLASTIC 99 .OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I cerHry that this UST system Is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliancewithlejal requirements. APPLICANT SIGNATURE,--' c� ,. o q tr DATE 4Io' / ` � 13 APPLICANT NAME(print) 4t' APPLICANT TITLE 472' David H Rogers Director of Real Estate Development UPCF UST-11-1/2 Rev.(12n997)