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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT A PPI.IrATIfIN _ TA nor 1 W Vf%n%A A Tank 4 a ava'l lune roan cr U81f)' � TYPE. OF ACTION (Check one item only. For at CST pen -)anent closure or removal, complete only this section and Sections L 11, Hf A' and IX her )9 I) 4 ❑ I. NEW PERMIT ❑ i. RENEWAL PERMIT 5, C'IIANGE OF INFORMATIONEl qp 6. TEMPORARY LIST CLOSURE F1 i. UST PERMANENT CLOSURE ON SIT[ k. UST REMOVAL DATEIJSTPttRMANP.NTLY('[.OSF.D: +i1M1' D:\'1P: FXIS'I'INli 1;$f DISC'OVERISD: 439h I. FACILITY INFORMATION FACILITY ID N I:Igru, ( f;er Only, t BUSINESS NAME (Same as FACILITY NAME ar DBA -Doing Business As) r Costco Gasoline (Loc. No. 38) BUSINESS SPIE ADDRESSIID C'I'fY 1616 E. Hammer Lane IM Stockton II. TANK DESCRIPTION TANK ID r.* O,r�O�ejD +. TANK VI;\Nl1F:\CTUIt F.R 4'1 'TANK ('ONFI<;UR.4TION: THIS TANK Is 4u 4 @ L A STAND-Al.OSH TANK Containment Solutions ❑ ), ONF: IN d COMPARTM1ILN I ED UN'rf . UA'I"E US'f SVS"FEM INS'I"ALLI'.D 4)5 TANK CAPACITY IN GALLUNS +!6 11Y' „O I NUMBER OF COMPARTMENTS IN THI UNIT' 45T TBD 1,500 1 Ill. TANK USE AND CONTENTS 'TANK USI:' Q le MQfOR VFHII'I. F FUFI IMG ❑ IN MARINA D:kl ING Q Ir AVIA TION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE Q 4. HAZARDOUS WASTE 11101W,+ Used Oil, ❑ 5. EMERGENC'YOF.NFR.4TOR FUEL IHs(423,1s I.A9q ❑ h.OTHERGENERATOR FUEL Q 95. UNKNOWN ® 119.OTHER ISII 1; Fuel Additive +39s CONTENTS PL'I'ROLBU\1 ❑ 11 RFGIIL AR l'\'l Fn DIi) ❑ Ic hu lx iR:1OI° CNLIIAIR:U Q 11, PREM 11N1 UNLEADED 1+9 ❑ 3. DIESEL Q 5. JET FUEL Q n. A\ [A TION GAS ❑ N. PFTROLFUM Fit FNO FUFI. QI 9, OTHER PF I ROLF:UM fS ecdH: Fuel Addltive -- (^Lv�a^� NON-PFTkOLFUNi- '. IISFDOII. 10. FTIIANOI. 11. OTHER NON.PETROLEC%I S x"iPo : 4 A IV. TANK CONSTRUCTION TYPF.OFTANK I.SINli1.E NVALL 17 '2. DOIIRLF. W'ALI. Q95.1;NKN0V,N bl] PRIMARI'('ONl'.41NM1IEtlI' L SI'EF.L • i FIBERGL 4S5 n, IN'I'kRNAL tlL4 L1UFR 4J4 ❑ 7. STEEL I INTERNAL LINING ❑ 93. UNKN0IVN ❑ 99" OTHLR (S eifvc 444. SECONDARY CON IAINMI. NI Q 1,SIFE1_ M. I. FIHP.RGLASS ❑ h.IiXTF.RI(3RMF. NIHRANII LINDA Q 7.)A('Kilfl!0 4+5 411.N01- 9.5 IFNKNOW'N 9V. UTHFR(5ar'f1. 443. UVFk F II.I. PRFVF.NTION • I. Al1UB{i F.@ VISIRI. ALARMS ?. HALL F1.7 IN i. I'll 1. TURF SHUT-OFF VALVE 451. ❑ 4, TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSIN(iLF-N'4LLFD 1DOL'BLF-W'ALLF.0 0 W. OTHER 41,0 SY5TL'hI TY PE 0 1.PkCssl'RE 0 _'.GRAVITY 3. CONVENTIONAL SUCTION 4. SAI "E SUCTION 23 CK U6361u631 +31' PRIMARY ('ONT.AINNIFN i LJ I S I I l l U@ 4 199FRUI ASS ❑ S, FI. FAIRIF U In RIUID PLASTIC 464 Q 9o. NONE Q 05" UNKNOWN Q 99.OIJILRlSwc.kt: 464E SECONDARY CONE\IS?II:Nf ❑ 1. STLEL (E 4. HBLRGLASS Q N. FLEXIHLG In RIGID PLASTIC L>Ih ❑ Vo. NONE ❑ 95. UNKNOWN Q 99.OTHER IN.M. 464. PIPINGIURBINk('ON I AINn1 I'N I' SUMP I YI'E I. SINGLEWALL a 2. WUBLE \PALL 171 90. NONE 464a %T VEN'I', VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT VRINIAR)' C'ONI':\ INNIF NI' L51"BFI.111 1HHFROLAS9 LJ In RIOIOPLASIIC 0 911 NONE 0 4V.(OVIEKISPwiv) 464, 4e1 VENT SB('(1NLh\R5'C'ON'IAINh1ENl' 1. 51'EEL +. PIHP.RCiLASS 10 RIGID PLAS"I1(' 411, NONC V9.(vl'HER ISpccify) 4eNf n VR PRIMARY CONTAINMENT LJ I. STIFF1 E3 J. FIRFHGLASS In. RIGID PLASTIC VII. NONE: 9'1, OTHER ISpnifyl 4Wr FIc1 \B SCCONDARI'CONTAINhIENT 1. STEEL 4. FIBERGLASSLj Io. RIGID PLASTIC 90. NONE 99.OTIIER ISp, ify) 4Wh Wh1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE \1`,LLL • 2. DOUBLE WALL 00. NONE 4641 RISER PRIMARY CON'I'AI%NIFN"f I. Sl -4.1'In RCI.ASS In. Mill) PI..AS III U 90. NONE EI 99. UI'HP:R(Specify) 4N) 4W I RISER SECONnARYCONTAINN{ENT U I. STEEL . 4. I-RniRfil.:\SS 0 10, RIGID PLASTIC M 90, NONE U 99.0TIIERFSpecifc3 4641 44k1 FILL COMPONENTS INSTALLED e I. SPILL BUCKET a ). STRIKER MATE., DOTTOM PROTECTOR ■ J. CONTAINMENT SUMP 4519. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE. Q LSINGLF`AA II. Q 2_DOURLF"MV Q i. NO DISPENSERS 1@ 90. NONE 4194 C'ONSTRLICTIONMATERIAL Q I. STEEL 4. FIBERGLASS Ll 10.RRADPLASTIC Q 99.OTIIER IS VIII. CORROSION PROTECTION S' I'E EL COMPONENT' PRUI ECT ION ❑ ', ya('RIFIC'I:\L ANODE(S) ❑ J Afl'RESSED('URRkN"I' ❑ ,. ISOI. A IION -- IX. APPLICANT SIGNATURE CF.R-1'IFICA'I ION: I certify that this LSI 11 Stein is cnnlpatible x1th the hazardous suhstonce stored and that the information provided herein is true, accurate. and in fill] rum Inol With Ic al c uiremenis. ®E$LI�cWI,61GI1r1TlILE A?A14 Z APPLICANT N'ANIF (print) I.I APPLICANT TITL' David H R ers Director of Real Pmen] VPCF LIST -B- 112 Rev. (12120117)