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do `11.. A a BCE#10199 Tank UNIFIED PROGRAM CONSOLIDATED FORM�� I UNDERGROUNDSTORAGETANK It t7 ' OPERATING PERMIT APPLICATION - TANK INFORMATION (One fo m e uST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, II, III, IV, and IX below) 430 ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4301 I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Costco Gasoline (Loc. No. 38) BUSINESS SITE ADDRESS 103 CITY 106 1616 E. Hammer Lane Stockton I1. TANK DESCRIPTION TANK ID#432 1 TANK MANUFACTURER 633 TANK CONFIGURATION: THIS TANK IS 034 2 Containment Solutions 0 1. A STAND-ALONE TANK 02. ONE NACOMPARTMENTED UNIT. Complete one pipe, for each com mne.t in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 March 2004 20,000 1 III. TANK USE AND CONTENTS TANKUSE N Ia. MOTOR VEHICLE FUELING ❑ IT. MARINA FUELING ❑ k. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil ❑ 5. EMERGENCY GENERATOR FUEL IHSC §25281.5(.)) ❑ 6.OTHERGENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: 0 Ia. REGULAR UNLEADED ❑ k. MIDGRADE UNLEADED ❑ IN. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. SET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 44W NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ II.OTHER NON -PETROLEUMS .ci(): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 0 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL N 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 404 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): edea SECONDARY CONTAINMENT ❑ 1. STEEL 0 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 005 ❑ 90. NONE ❑ 95. UNKNOWN ❑99.OTHER (S eci ): 445a OVERFILL PREVENTION 1. AUDIBLE&VISUAL ALARMS E 2. BALL FLOAT 113. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE -WALLED E11) E -WALLED ❑99. OTHER 460 SYSTEM TYPE E 1. PRESSURE [12. GRAVITY 1_13. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION I23 CCR §363da)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS E & FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS M 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 0fi4c PIPING/TUFIBNE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 90. NONE died VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT' PRIV ARYCONTANMENT ❑ LSTEEL N 4. FIBERGLASS [110. RIGID PLASTIC [190. NONE [199. OI HER(Spceify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ LSTEEL E 4. FIBERGLASS ❑ lo.RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4Mf 46,M VR PRIMARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 46411 VENT PIPING TRANSITION SUMP TYPEI. SINGLE WALL ❑ 2. DOUBLE WALL [190. NONE 464'. RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641, 464k1 FILL COMFONENTS INSTALLED 1. SPILL BUCKET 0 3. STRIKER PLATEIROTTOM PROTECTOR 0 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE E I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE. 469a CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT e 6. ISOLATION 40%' IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this US mpfitible with the hazardous substance stored and that the information provided herein is true, accurate, and in full com ce 'th le reg4iirements. APPLICANT SIGNATURE alo. . DATE November 20, 2012 4]I. APPLICANT NAME (print) APPLICANT TITLE 472. Jeff a Gasoline V.P. UPCF US'f-B -1/2 Rev. (1212007) w