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6mtFIED PROGRAM CONSOLIDATED FOk!rW r TANKS ° h UNDERGROUND STORAGE TANKS - TANK PAGE _. (rwo Pam Pa's) aaaaaaaaa Page_of_ TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check ane item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (specify reason) (Specify oaon) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILD'y14AME a DBA-wine Business As) 3. FACILITY ID: 1. Costco Gasoline Loc.No.0135 ATION WITHIN SIT (optional) a 631. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes No 434. 2 Containment Solutions If•wea^canplete ane pose far each campanaenr DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. 2002/05 20,000 1 ADDITIONAL DESCRIPTION(For foul use only) 438. 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 440 19 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (IfcheckeQ canplate Penolemn Type) ❑ Ib. PREMIUM UNLEADED El 3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (fian Harasdom Materials Invmto y page) 441- CAS#(gran Hazardous Materials inventory me) a42. ❑ 4. HAZARDOUS WASTE 87 Octane 8006-61-9 (Incmdea Mcd an ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-primary tank 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN aha. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL N3. FIBERGLASS/PLASTIC ❑8. FRP COMPTBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 466. DATE INSTALLED 4Q. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑I.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN Me, DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT _2002 ® I.ALARM _2002 ❑3.FILL TUBE SHUT OFF VALVE ®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 454. (Check all 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 INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR),BIENNIAL TANK TESTING [3 99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 411. gallons []Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00