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tlidMD PROGRAM CONSOLIDATED FO)Mt TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ® L NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ a.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 1 FACILITY ID: Costco Gasoline Loc.No.0135 LOCATION WITHIN SITE optional) 431 s o c u 1.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 M No 434 3 Containment Solutions if"Yea,"complete one page for each Compartment DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2002/05 20,000 1 ADDITIONAL DESCRIPTION(Forlocal use only) 438 Installation of 3-20,000 gallon underground gasoline storage tanks and associated product piping and monitoring systems. H.TANK CONTENTS TANK USE 434. PETROLEUM"TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (lf checked,complete Petroleum Type) lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous M.Wrials Inventory page) A41 CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE 92 Octane 8006-61-9 (Includes Used oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SINGLE WALL WI Fill EXTERIOR ❑5. 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-primar.-urnk ❑ 1. BARE STEEL 3. FIBERGLASS I PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check we item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W1100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 0 3. FIBERGLASS/PLASTIC ❑8. FRP COMPT113LE W1100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRF) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED 3.EPDXY LINING ❑S.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447, OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT Cl 99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 1 TYPE 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) 10 1.SPILL CONTAINMENT 2002 N I.ALARM _2002 ❑3.FILL TUBE SHUT OFF VALVE 0 2.DROP TUBE 2002 Z 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 ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456- TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1199)-1/4 http://www.unidocs.org Rev.02/16100