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a • Tank 4 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK t' OPERATING PERMIT APPLICATION - TANK 1NFOR.MATION (one t m dr s()(^/ TYPE OF ACTION (Check one item only. For an CST permanent closure or remnlal, complete only this section and Sections L 11, III, IV, and IX het 'I 440 C) 1, NEW PERMIT [13. RENEWAL PERMIT M i, C'IIANGE OF INFORMATION I/ 6. TEMPORARY UST CLOSURE T UST PERMANENT C'LOSI RE ON SITE R. UST REMOVAL ` / 0:111' 11S'F PERMANENTLY ('LOSI'.D. " ' I DATE FXISTIN(i UST DISCOVERED: L F:ACILI'IY INFORMATION FACILITY ID k (dgenn Use On/0 I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) Costco Gasoline (Loc. No. 38) BUSINI itis SI'TL ADDRI'SS 1"? C'I"1"Y IW 1616 E. Hammer Lane Stockton 11. TANK DESCRIPTION L\\K IUQ,Ci7O�e1D TANK M;\NIIFA(CTL'RER 4" I Ant:( ONFILF R%IION TH is I.XNK IS 4U (6 U El sllvNu-:uONt 1vNn 4 Contalnment Solutions ❑? ONF IN A(a\(PARI M1fLN IFU (TIT. tl. i Tel, xOa u [ 1,n each unn achi,u9l i� n,. n0il DAT(' UST SYSI-17M INS 'I"AI 11'1) 4^ '1';\NK CAPACITY IN GALLONS 4'6 NUMBER OP COMPARTMENTS IN THE UNIT TBD 1,500 1' III. TANK USE AND CONTENTS TANKUSi. ❑ U MO'IORVEHIL'LEF'UELING O Ib MARINA FL F NO ❑ Ir .AVIAIIONFUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE 04. HAZARDOUS WASTE Hndudee Uxd Oill 05.FMERGF.NC-Y GENERATOR FUEL(11s(4252619,1 Cl 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 19 99. OTHER (S scTy): Fuel Additive 4w. CONTENTS PETROLEUM ❑ la REOULAR CNLEADED ❑ Ic. MIDGRADF UNt.I-:M)l D 0 1 . PREMIUM UNLEADED JJ0 ❑ 3. DIESEL ❑ S. TFT FUEL 0 6 AVIATION GAS ElN. PF"TROLEUV1 BLEND F1 FI Q 9. O'FHFR PFTROI f9.\I IS catvl: Fuel Additive- LUt�+•'; (y/ % D�pi1tu N0N4'FTROI FIIM' 7. USED 011. In. FTI I ANI )1 I I.OTIIER NON-PETROLLI IS xcif is 4401, IV. TANK CONSTRUCTION TYPF. OF TANK 0 I. SINGLE HALL IN 2, D011BI,F WALL 0 95. UNKNOWN IH PRIMARY CONTAINMENT ❑ I. STEEL IN 3. FIBERGLASS ❑ 6. INTERNALBLADDER 444 ❑ 7. STEEL' INTLRNAI-LINING ❑ 95. UNKNOWN ❑ 49.01HLR specify): 144° SFCONDARY CONTAINMENT 0 I. STI?PJ_ IN 3, FIBERGLASS 0 6. FXTHRIOR MI-: N113RANI LINER 0 7AACKETED 44` ❑ 90. NONF ❑ 95, UNKNOWN 0 99. OTHER (S Net)P. A3`. OAT 3. FILL TURF SIIUT-OFF VAI VF 4Y_ OVFRFII.I. PVFNTION ■ I, AUDIRLF. & VISUAL ALARMS 0 2. BALL FL ■ RF ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLF,-WALLED M 2. DOUBLE -WALLED 0 99, OTTER 40, SYSTEM TYPE m I. PRESSCRE ❑ 2. GRAVITY ❑ 3. ('ONVLNTIONAL SUCTION 0 4. SAFE STICTION I' ('R i2636(.µ3) 439 PRIMARY CONTAINMF NT 0 1. S'IFF'1. (M 4. FIBFRUTASS ❑ N, FIE.XIHlF U TIL RIGIDPLASII(' 464 0 90.NON1 ❑ 95, UNKNOWN ❑ 99,011IERI9 city): 4641 SECONDARY CONTAINNIFNI' ❑ L NIELL [1] 4. FIBERGLASS ❑ N. FLEXIBLE ❑ 10. RIGID PEAS I'I( 4Nh ❑ 90. NONE ❑ 95. UNKNOWN ❑ 94. OTHER (Sr,ohr. 464. PIVIN(i TI'ROINF CONT.AINMENI' SIAfP 1) PF ❑ GI](fl F \1.\I I I] '. POI'HI L R 1I I ❑ •+u \(,Nl 4 L VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONS I RUCTION VENT" PRIMARY C'ONTAINMEN'f I. S11:1I. Cil I. FIBERGLAS ❑ 10 RIOIDI'LASI'IC ❑ 911. NONE ❑ 99 p 1111' R(Sp,o Nl 4Me 4t I VENT SECONDARY CONTAINMEN I' ❑ I. SILF_1 IN 4. FIBERGLASS ❑ 10 RIGIDPLASI'IL' ❑ 90. NONE ❑ 'P) OIIIERXp,ellyl 4Mf 4M11 VR PRIMARY CONTAINMENT 0 1. SIFFI ❑ 4. FIRFRGI.ASS ❑ IO. RIGID PLASTIC O 411, NONF 0 99. 01HF.R(Spa:Uy l 4", 464 I VR SECONDARY CONTAINMENT 0 I. STEEL ❑ 4. FIBERGLASS 10RIGIDPLASTIC CC 90. NONE 99. OTI IER(Specify l 4Mh 4"h1 VENT PIPING TRANSITION SUMP TYPE El 1. SINGLE WALL • '-. DOUBLE WALL Q 90. NONE 464' RISER PRIMARY CONTAINMENT n I. STlilil. Lj 4. FIBERGLASS U 10 -RIGID PLASTIC ❑ 90. NONI U 119. 0111I.R (Spccif9) 4M1 IW1 RISER SECONDARY CONTAINMENT D 1,STEEL 0 4.17mERGLASS 0 10, RIGID PLASTIC 8 90. NONE LJ 99. OTIIF.RISpe,d',i 4Mk 4WH FILL COMPONENTS INSTALI. FD ■ I.SPILLBUCKET ■ 3.STRIKFRPLATF1IorTOh7PROTFCTOIt ■ 4.CONT46\II'NTSI'SIP 4'1+-, VII. UNDER DISPENSER CONTAINMENT (UDC) ('ONSTRI'('TION T1111 ❑ I. SINGI F. WAIL 0 1 DOURLF W'Al I 0 3. NO IIISPFNSFRS Q ')11. NONE. 4"y° R0NS1 Ill:(' TION MATI. RIAL ❑ I. STILL 0 4. FIBLRYd _ASS ❑ 10. RIGID PL\i I'It ❑ 99.0THER(S •cif) VIII. CORROSION PROTECTION STLELC'UVNIM AI PIt11111 II -IN ❑ ISACRIFICIV ANODN,SI ❑ J %1PRESEDCURREN'I ❑ 6. ISOLA TION -' IX. APPLICANTSIGNATURE CERT'IFIC'A I ION: I certify that this LST" %'stem is cumpvtible with the haiardous substance stored and that the information provided herein is true, accurate. and in full compliance %ilh Ie a I c nirements APPLICANT SIGNATURE, DATE APPLICANT NAME (pont).ANT TITL . - David H F ers Director of Real Estate Development u UPCF UST -B -112 Rcs, (1212007)