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nt:Gjll U Yv Hank UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, II, III, IV, and LX below) ❑ 1. NEW PERMIT 430 ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 4JOe rDATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) J BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) Costco Gasoline (Loc. No. 38) 3 BUSINESS SITE ADDRESS 103 CITY 1616 E. Hammer Lane Stockton 104 II. TANK DESCRIPTION NK ID # , . l:c 432 [ TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 (' 14✓ AL 1 1. A STAND-ALONE TANK ;DATE Containment Solutions ❑2.ONE INACOMPARTMENTED UNIT. UST SYSTEM INSTALLED 435 ch 2004 TANK CAPACITY IN GALLONS 436 Com lege one pace for each compartment in the unit. NUMBER OF COMPARTMENTS IN THE UNIT437 20,000 III. TANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE, FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE unclad. Used Oil ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(.)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ]e. REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S eci 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ I L OTHER NON -PETROLEUM S eci ): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL 0 2. DOUBLE WALL ❑ 95. UNKNOWN PRIMARY CONTAINMENT ❑ 1. STEEL 0 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 443 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL F 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7, JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (SpccifA: 445a OVERFILL PREVENTION 1. AUDIBLE &VISUAL ALARMS f 2. BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUC1lON ❑1. SINGLE -WALLED W2 -DOUBLE -WALLED ❑99, OTHER 460 SYSTEM TYPE 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS IN 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS t] 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4Mb ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGrr1 RBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL I] 2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify) 464e VENT SECONDARY CONTAINMENT LSTEEL � 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90.NONE 99. OTHER (Specify) 464el 46ar VR PRIMARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 46411 464, VR SECONDARY CONTAINMENT464 ❑ 1. STEEL 4. FIBERGLASS ❑ ]0. RIGID PLASTIC ❑ 90. NONE 99, OTHER (Specify) 1 4Mh VENT PIPING TRANSITION SUMP TYPE 0 I. SINGLE WALL4MM ❑ Z. DOUBLE WALL ❑ 90. NONE RISER PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ ]0. RIGID PLASTIC ❑ 90. NONE ❑ 99.0THER (Specify) 464,, 464, RISER SECONDARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC W. NONE 99.OTHER (Specify) 464,1 464k 1. SPILL FILL COMPONENTS INSTALLED BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP 4Mk1 4513-c " VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I] L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4. FIBERGLASS I] 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT M 6. ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that [his T syste is mpatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full eo m e wit r uirements. n95 APPLICANT SIGNATURE DATE 47- 20, 2012 V 471. APPLICANT NAME (print)Je APPLICANT TITLE 472. C e Gasoline V.P. UPCF UST -B -1/2 j, � efrti ,s1 {,�„�V,_ Rev.(12/2007)