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h FLED PROGRAM CONSOLIDATED FO` r p y� TANKS v 3 a ora UNDERGROUND STORAGE TANKS - FACILITYge site) i Page-Df 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400TYPE OF ACTION ®I.NEW PERMIT ❑3.RENEWAL PERMIT ❑8.TANK REMOVED (Check one item only) C34.AMENDED PERMIT (Specify change) ❑6.TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION BUSINESS NAME(smaeas FACILMNAMEm DBA-Doing Business As) 3, FACILITY 1. Costco Gasoline Facility No.0135 NFA REST--CROSS STREET 3L-3p _ ao1. FACILITY OWNER TYPE 0 4.LOCAL AGENCY/DISTRICT' Tracy MarkethlacelGrantline Road 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESS M 1.GAS STATION ❑J.FARMIN 5.COMMERCIAL °03 ❑Z.INDIVIDUAL ❑6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR C]4.PROCESSOR E]6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 4% Is facility on Indian Reservation 405. •If owner of UST is a public agency:time of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) 3 ❑Yes ®No IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408. Costco Wholesale Corp. (425)313-8100 409MAI0TG OR STREET ADDRESS 999 Lake Drive 4u. ZIPCODE 412 CITY 410. STATE Issaquah WA 98027 PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCALAGENCY/DISTRICT 6.3TATEAGENCY 4O ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III. TANK OWNER INFORMATION TANK OWNERNAME 414. PHONE 415. Costco Wholesale Corp. (425)313-8100 416 MAILING OR STREET ADDRESS 999 Lake Drive CITY 417, 1 STATE 418. ZIP CODE 419. Issaquah WA 98027 TANK OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. ❑3.PARTNERSHIP [-15.COUNTY AGENCY ❑7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 0 1 3 1 9 1 1 1 0 1 0 1 Call(916)322-9669 if questions arise 421. V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and nuilings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423, VII. APPLICANT SIGNATURE Certification: I certify that the information provided h is we and accurate to the best of my knowledge. �f SIGNATURE O A 1 DATEAT eu. ONE 4L7-765325. NAME OF APPL T(print) 426. TITLE OF APPLICANT 427, STATE UST FACILITY NUMBER(Agenq we only) 428. 1998 UPGRADE CERTIFICATE NUMBER(wgency use only) 4W. (See Data Element 1,above. UPCF Hwfwre-a(1199)-1/2 http://www.unidocs.org Rev.02/16/00