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M ! BCE #12919) <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATIO, <br /> (ilex linin IW, I'aeilityJ <br /> TYPE-OF ACTION ❑ I.NEW PERMIT R 5.l'l1ANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE J°0 <br /> r('I,eck mm 1)1414 md.1 <br /> ❑ 3.kl+Nf•.\VAI.PERMIT ❑ h.IEMI'ORARI' FA( ILI TY( I.OSIJRE ❑ 9.1 R,INSF EI(PCRMI l <br /> 1. FACILITY INFORMATION <br /> 101AI NUMHEROFUSTs AIFACIL1Y 0.. I mcilI I 1118 <br /> 3(Existing)and 1 (Proposed)=4 Total t,l1.; .(f„�,t — -- 1 <br /> HIISINF.SS NAMFIu,:.a ern ut aaw,,,111414 ta,Inc w,..,.,•.+., <br /> Costco Gasoline(Loc.No. 1031) <br /> HUSINESSSITEADORESS I°' C'11'Y nu <br /> 2440 Daniels Street Manteca <br /> FA(11 I'I')"I-YPI: ❑a I.\10'rOR\'hlll('LI'.I;UIl1.IN(i401 -- -"`— T”❑ 2.I 111fI.DIS'rRl Rll'I'IUN Is the Iacihl) I"ealed un hulian Rexcnabon or <br /> 3.FARM 4.PROCESSOR Lj 6.(7TI IER Trost IandO ❑Ycs ®No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE <br /> Costco Wholesale,Attention: Licensing ( 425 313.8100 <br /> MAILING ADDRESS <br /> P.O.Box 35005 <br /> CITY n" STATE <br /> ZIP('(fUL n <br /> Seattle Washington 98124 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME --------------_-_ _... <br /> azs i 1'HUNF <br /> Dennis Bock,Costco Wholesale ( 425 ) 3138100 <br /> MAILING ADDRESS as <br /> 999 Lake Drive <br /> Crev srA rE :., a1r coD1?— <br /> Issaquah Washington 98027 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME +1+ PFIONE ns <br /> Costco Wholesale,Attention: Licensing <br /> MAILINADDRESs ( 425 313-8100 <br /> ) <br /> G <br /> P.O.Box 35005 <br /> CITY u' 1 STATE <br /> Zll CUI/E +n. <br /> Seattle Washington 98124 <br /> t llk'NVk I)TU ❑ 4.LOCAL A(RLNC'YVIti TRIC I- ❑ 5 COUNTY AGPN('Y ❑ 6.SA'T'E A(;I:N(')' a+u <br /> ❑ 7.FEDERAL AGENCY 9 M.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY 1TK)H 44- 0 <br /> Q 3 9 1 0 O fall the Stale Brurd of Equalization.Fuel Tax On inion,if them are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Imue 1114"11131111 send legal mnilie:"arm and mmlings to: ❑ 1 FACIE 11 Y OWNER ❑ 4 TANK( PFRATOR r, <br /> Q \.TANK OWNER ❑ 5.FACILITY OFFRATOR <br /> -SlA TRVISOR OF 1lIVISIUN,SRC f lGN,UR(ff Fl('T Iltcquired Foi I'nhhc;\gamip(In119 "'0 <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certlh-that the inform On rovided herein Is true,aecel•ate,and in rail tam tianee with Ic al re uirrnfY`ryls. <br /> APPLICANT SIGNATURE DATE PI1O! <br /> 16b6 ( 425 ) 313.8100 <br /> :11'I'LICANT NAME going ' Al'I'LHA 1'IITI.. r <br /> David H Rogers Director of Real Estate Development <br /> { <br /> 77 <br /> IPCF USI-A Rev.t 12121)117( -. ,1 <br />