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i Itank) L,4tFIED PROGRAM CONSOLIDATED FOk`WTANKSUNDERGROUND STORAGE TANKS - TANK PAGE 1-/ Page_o TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (LTeck one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spai(yreaeoN (Specify reason) ❑ B.TANK REMOVED BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: Costco Gasoline Loc.No.0135 431. LOCATION WITHIN SITE(13ptieral) I.TANK DESCRIPTION (A scaled plot plan with thTANK MANUFACTURER UST system including buildings and hand niurks shall be OMPARTMEN ALIZED TANK to the local a Yes) No 434. TANK ID# 1 Containment Solutions If"Yes;' omplee one page for each compartment DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2002/05 20,000 1 438. ADDITIONAL DESCRIPTION(For local uu only) Installation of 3-20,000 gallon underground gasoline storage tanks and associated product piping and monitoring systems. II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE �0 ® 1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om Haesokwo Materials Inventory page) 4T'- (horn Han sohne Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE 87 Octane 8006-61-9 (Includes Used Oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARESTEEL ®3. FIBERGLASS/PLASTIC [j S. CONCRETE 095.UNKNOWN a4d. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) WIIW/.METHANOL TANK MATERIAL-secondary tank ❑ 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%4 METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED [199.OTHER (Check one item only) OTHER CORROSION ❑I.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN dog. DATE INSTALLED M9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451 FOVOUTILLPROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ®L SPILL CONTAINMENT _2002_ ®1.ALARM _2002 ❑3.FILL TUBE SHUT OFF VALVE N 2.DROP TUBE 2002 ®2.BALL FLOAT_2002 ❑4.EXEMPT ®3.STRIKER PLATE _2002_ IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453- IF DOUBLE WALL TANK OR TANK WITH BLADDER 45,1 (Checkall that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS IN'T'ERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING C1 99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE p/ A ESTIMATED DATE LAST USED(YR/MO/DAV) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL'1 457. gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-114 littp://www.unidocs.org Rev.02/16/00