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I,PCF (1ST -A Res•• 0212e117) <br />YA':'yM �C <br />r. , eb <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />VN <br />OPERATING PERMIT APPLICATION— FACILITY INFORMA Ir/Ihrr <br />(One fon( per facility) <br />TYPE OF ACTION ❑ L NEW PERMIT <br />R 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />"10' <br />(Chock ane itna unlet ❑ }, RENF\1hV.l'FRMIT <br />❑ G. I-EMIPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />FACILITY INFORMATION l ! i <br />TOTALNUM <br />•1. <br />3 (Existing) and 1 (Proposed) = 4 Total <br />FACILITY IDd 1 <br />olyru<;r <br />r. <br />IWSINESS NAMF.(N,,e,4�F.sr1111)%AV) tI,aon nrI,e w�.��.,,,.ur <br />Costco Gasoline (Loc. No. 38) <br />P g�o2 <br />DUSINLSSSI"IEADDRLSS <br />1616 E. Hammer Lane <br />Stockton <br />I'AC'IL.I'IY "I"YPE Q I, 11C1'I'UI21'GHIC'Lli I'LOi.LIN(i'`13 <br />❑ 2. PURL UIS"I'RII3U'rION <br />----------__-�- <br />Is the facility located oo 111Jia0 Resmalion or <br />ens <br />3. FARM Q 4. PROCESSOR ❑ (.OTHER <br />Trust fonds? ❑ Yes ®No <br />11. <br />PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME <br />467. <br />PHONE <br />sox. <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313.8100 <br />MAILING, ADDRESS <br />a(m. <br />P.O. Box 35005 <br />CITY <br />oo <br />STATE 4nzip( <br />OUE __._._____.___ <br />+'= <br />Seattle <br />Washington <br />98124 <br />III. <br />TANK OPERATOR INFORMATION — <br />TANK OPF.RATOIt :NAME <br />+ear <br />PHONF. — <br />Dennis Back, Back, Costco Wholesale <br />( 425 ) 313.8100 <br />MAILING ADDIUSS <br />999 Lake Drive <br />- <br />CFfY„-, <br />----- - -- ----- <br />S"I'A'fl( 21P CODIS <br />Issaquah <br />Washington 98027 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME <br />414. <br />PHONE <br />ar<. <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313-81.00 <br />M1AILINO ADDRESS <br />P.O. Box 35005 <br />('11Y <br />.us. <br />STATE alx <br />21P C'O)E --------------- <br />. <br />Seattle <br />Washington <br />98124 <br />OWNLR-IYPL,: ❑ 4, LOCAL AGENCY?DI.S'I"RICT <br />❑ 5. C'OL'N"IY AGENCY ❑ b. S'FA'I'E AGLNCY <br />'=u <br />❑ 7. FEDERAL AGENCY <br />Q R. NON•CrOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 10 13 9 1 0 0 <br />Call the State Hoard of Equalization, Furl Tax Disision. if there are questions. <br />+�r <br />V1. <br />PERMIT HOLDER INFORMATION <br />slue perms and sent legal nmiliartian> anJ nvlilinea m: <br />El 1, FACILITY OWNER[14. TANK OPERATOR <br />12, <br />l0 }. "f.ANK OWNER ❑ S. FACILITY OPERATOR <br />SUPHRV ISDI2 OF DIVISION. SE("iIUN. Olt UFFIC'F. I RcquircJ Fur Public Agrnnes Only) <br />oa. <br />VII. APPLICANT SIGNATURE <br />CERT IFICATION: I Ccrtifv that the irtfor,larlo,provided hrrein is true. <br />accurate. and in full compliance with legal requirements. <br />{rl : ,sir{ ,( /� <br />A611, 1.1. <br />PHO\E <br />125. <br />YD p(i <br />'I ?-- <br />( 425 ) 313-810 <br />APPLI(ANI NA: F:(prinrl <br />'=' <br />APPLICANT"ffLL's <br />+=7 <br />David H Rogers <br />Director of Real Estate Development ^Y ���ii <br />I,PCF (1ST -A Res•• 0212e117) <br />YA':'yM �C <br />r. , eb <br />