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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one Form per usT) <br /> TYPE OF ACTION (Check one idem only. For a UST closure or removal,complete only this section and Secdons 1,11,111,1Y and IX below) 430 <br /> Q L NEW PERMCT 0 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE rl S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. I DATE EXISTING UST DISCOVERED: 43c6. <br /> L FACILITY INFORMATION <br /> FACILITY 1D#(Agency Use Only) i <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) , <br /> Costco Wholesale SM station#658 <br /> BUSINESS SITE ADDRESS 303. f 11 Y <br /> 3250 W. Grand Ave. Trac <br /> H. TANK DESCRIPTION <br /> TANK TD# 432, TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> Two Containment SOlut10t1S IN 1.A STAND-ALONE TANK Complete ore page for cb <br /> 11 2.ONE IN A COMPARTMENTED UNIT conTwmnt n the a j&. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMEN'T'S IN THE UNIT 437. <br /> Sept.2402 20,000 4 <br /> III. TANK USE AND CONTENTS <br /> TANK USE N M.MOTOR VEHICLE FUELING e3 Ib.MARINA FUELING L7 le.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(locw.Used oo) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 12526I.5(01 <br /> 6-OTHER GENERATOR FUEL___ 1395.UNKNOWN_ _ _❑ 99.OTHER(Specify)_ 439 <br /> CONTENTS PETROLEUM: ® Is.REGULAR UNLEADED [31c.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. <br /> ❑ 3,DIESEL ❑ S.3ET FUEL ❑ &AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL [39.OTHER PETROLEUM(Specify): 440x <br /> NON-PETROLEUM:[37.USED OIL - ❑ 1D.ETHAN6L <br /> ❑ 11.OTHER NON-PETROLEUM 5 i : 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK C37,SINGLE WALL C 2.DOUBLE WALL ❑ 95.UNKNOWN 443- <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS 06.INTERNAL BLADDER 444. <br /> _ [17.STEEL+INTERNAL LINING [3 95.UNKNOWN [3 ". <br /> 99.OTHER(Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [37.IACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS J§ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT I WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION_ ❑ L SINGLE WALL_® 2.DOUBLE WALL [399.OTHER _ 460. <br /> SYSTEM TYPE - R 1.PRESSURE ❑Y2.GRAVITY ❑ 3,CONVENTIONAL SUCTION 134.SAFE S(JGTIQN 123 CCR;26J6(rx311 <br /> PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 0 &FLEXIBLE -- <br /> ❑ 10.RIGID PLASTIC 464. <br /> __ _ _ ___ [390.NONE ❑ 95.UNKNOWN E3 99.99.OTHER(specify). 444 <br /> SECONDARY CONTAINMENT` ❑ 1.STEEL ❑ 4 FIBERGLASS 11 &FLEXIBLE <br /> ❑ 10.RIGID PLASTIC 4646. <br /> ❑ %NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x- <br /> PIPING1rURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL Q 2.DOUBLE WALL ❑ 90.NONE "A& <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBEItGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464x1. <br /> VENT SECONDARY CONTAINMENT -_-.,-- <br /> I.STEEL ® 4.F1BQtGLA55 ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): <br /> 46411. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL C§ 4.FIBERGLASS Q 10.RIGID PLASTIC 1390-NONE ❑ 99.OTHER(Specify); 4464 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9o.NONE [399.OTHER(Specify): 4641L <br /> - -- 4641. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALT, ❑ 2.DOUBLE WALL 09 90.NONE -- 7641 <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Spectfy): 464 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL (34.FIBERGLASS (310.RIGID PLASTIC ® 90.NONE [399.OTHER(Specify); a`btk4" <br /> FILL COMPONENTS IlVSTAI LED 1.SPILL BUCKET ®-3.STRIKER PLATV13OTMM PROTECTOR 4.CONTAINMENT SUMP 45 i rc <br /> VII. UNDER_ DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE --- ❑ I.S(NGL.E WALL a 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469., <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL N 4.FIBERGLASS 0-10.RIGID PLASTIC 13 99.OTHER(Specify) - -46 <br /> 4699b <br /> c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE S) 134.IMPRESSED CURRENT 6.[SOLATION 441. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I cerdfy that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and In full compliance with legal pgairements. <br /> APPLICANT SIGNATURE DATE10/5/2009470. <br /> APPLICANT NAME(print) Denllis Bock 471 APPLICANT TITLE Compliance Manager 477 <br /> UPCF UST-B Rev.(12/2007)-I/2 www.nnidocs.org <br />