|
V • Ah
<br />Tank 4
<br />5, r UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TANK
<br />OPERATING PERMIT APPLICATION -TAN INFORMATIO
<br />nm er UST)
<br />TYPE. OF ACTION (C'heck one ilem only. Foran CST permanent closure or temnval, complete nniv this
<br />section and Sceiions ffN Ivry h
<br />❑ I. NF,'W PERMIT ❑ 3. RENEWAL PERN7IT i, ('IIAN(iF, OF T7C1�;
<br />El G. TEMPORARY
<br />I+I
<br />y�C„yI(RA.a
<br />UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE R. U5T REMOVALL``'-'''�' ✓J
<br />'5
<br />DA7li UST PERMANENTLY ('LOSEUL J70'
<br />DA'I F. PXIS'I ING UST I)N"(1Vf:RFD: •` ,
<br />Don
<br />L FACILITY INFORMATION
<br />FACILITY ID @ (:lgrnll I:h• URhI
<br />- _
<br />BUSINESS NAME (Sam, as FACILITY NAME ur DHA -Doing Business As)
<br />Costco Gasoline (Loc. No. 38)
<br />1
<br />DUSINESSSIIL ADDRESS ue City
<br />1616 E. Hammer Lane �recklon
<br />uu
<br />11. TANK DESCRIPTION
<br />TANK IfIg u: i;WK\tANt1FA('TURF.It 4!1 raNK CONFRAIRA HON: THISTANK Is ---
<br />u,
<br />4 ❑� I, ANTANO-AI ONI-TANK
<br />Containment Solutions
<br />❑, 0NF6ACONIPARMIFNIh.DUNI1.
<br />DATr mnnkl.•.n.•naA: lix ,...,,n
<br />UST SYS'I'I!A91N5'fALLEb 435 TANK CA PAC'll'Y IN GALLONS +'�• NUMBER OF C'OMPARTMIs IS IN "I"HI! UNIT•
<br />TBD'
<br />TBD -
<br />+!'
<br />1,500 1
<br />111. TANK USE AND CONTENTS
<br />"TANK USE ❑ la h101"OR VRHICI EFUELINO ❑ Ih MARINA FUELING ❑ Ir ZION FVFI ING
<br />,AVIA
<br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4.IIA7M1RDOUSWASTi11nJuJo Us,4Di1I ❑ S.FNTI.RCF.NCYGFNFIIATORFUFLIIISI',252si5.c,I
<br />419
<br />❑ h. OTHER GENERATOR FUEL ❑ 95. LINKNOWN E Q4. OTHER (Sj%dty l: Fuel Additive
<br />ata,
<br />('ONTENTS FL.ROLHAt: ❑ la R1,011 AR t. NI LADED ❑ Ir NIIOGRADL UNI LNiFD ❑ Ill. VRLA111171rNI.I:ADLD
<br />❑ ). DIESEL ❑ 5. JIT FUEL ❑ h, AVIATION GAS
<br />w
<br />❑ R. PKI ROI FUM 111 FND FUEL 9 9.01'HFR FFTR01 FUSI IS "IM; Fuel Additive
<br />114,
<br />NON-11FTROI LIIR1 T, IISFOOII 111, FTIIANO[
<br />11. OTHER NON-PETROLEL:M i' •ciF
<br />HVn
<br />IV. TANK CONSTRUCTION
<br />TYPE. OF TANK ❑ I. SINCI R WAIL Q 2, DOIIRI F. WAI.1. ❑ 95, IfNKNO%VN
<br />PRIMARY ('UN IAINMLN I - IRIEEL Q;. FIBEKUI-4R5 Q h, INI'LKNAL BLADDER
<br />III
<br />❑ i. STILL• INTLRNAI. LINING 095. UNKNOW N ❑ x).00IER (Sp.ary f.
<br />yw
<br />4444
<br />SECDNDAK Y CON IAI.NNI h.N I' ❑ LNIli1f1"
<br />.;SPIBFRGLASS ❑ h.PX ll:k ll')R SII MRRAVIII INbR ❑ i JAIKGIIO
<br />❑ vfI. NUNF ❑ 9S,❑NKNLIWN99.OTNFR(S ."hl
<br />C3
<br />DVERTRI I'kfVf-.NTION 1. AI1DIIa1 F& VISHAI AI ARMS ❑2.IiAlI FI O.4T �;. FIILTIIIIF
<br />4L•
<br />441,
<br />SIIIIT-l1FF\SVT VF
<br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION
<br />4{
<br />FROM OVERFILL PREVENTION EUOI I'NfENI'
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION❑ I.SINULEAVALLED e2. DOUBILTAVALLF"D 99.OT'iIF,K
<br />SYSTEM T\'PE • LPKESSIIRE 2
<br />❑ ❑ ,(;RAV TV ❑ )IAONVENTiDN.A L SUCTION Q 4 SAFLS ICTION L:t4'R 1)n!n;au)Q
<br />TNIMAk1'rDNT,AINRIENT
<br />4„I,
<br />45r
<br />I. STFF7 !, FIRFKfiI ASS ❑ R. FI FSIIil F ❑ 10 KIliID I'1 ASTIC
<br />4.1
<br />❑ 90. NONI: ❑ 95111NKNINi'N ❑ 99.OI HI:R(Sw,,ryj:
<br />�L+a
<br />SECONDARY CON f:111,11i!ENT ❑ I.STELL Q 4,IIIBMILASS ❑ N. FLEXIBLC ❑ 111 RIGID PEAS CIL
<br />❑ 411. NONE ❑ 95. LINKNOW'N ❑ 94, 0114ER(Sp.ml) 1:
<br />Ona,
<br />YINNUIURBINE CONI AIN'AIEN CSI1NT1-11'11L I. SINULE IV': a 2.00URI I,'' dI, ❑9n NONE
<br />an4.
<br />4hu
<br />Vl. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br />VENT'I'RIMARS'('ONl'AINhIEN-h LSTEE'L U CF'IBERULASS El In R1110MASHU 4n. NONE 94.OI1iERISperdyl
<br />41:,
<br />VLN'1 SLL'ONPAXY MN IAINNIEry I' L SIIiEL � 4 I`1HLRliLASS ❑ In RIf!ID FI aS ill' ❑ 911 ryUYL 44 OIHLR ISpcidy
<br />xaI
<br />4<af
<br />VR PRIAIARY l'ONTAINMGNT L Sf EF.I ❑ 4"FIRER(iI ASS Q lit RIGIDI'IASHL' Q 911, NONF. 99.11TirTR l Spealy'1
<br />4hJ11
<br />IMg
<br />VR SECONDARY CONTAINMENT L STCCL i. FIBERGLASS Q 10. RIGID PLASTIC 4u"NONC e9.OTfIHR ISpe:ifyl
<br />Int:I
<br />awe
<br />VENTPIPINGTR4NSITION SURIPTYPE I. SINf:!k. 11',111,. I !_.; !. ,) n, N:
<br />•
<br />- '_. DOf. B!- `4,11 O, L
<br />Iwll
<br />.IL ,
<br />NNLK PKI NIA KY('ON I'AINN'Il'_NI' LSI F:P.1. 4, 11HLR(II.ASS 1O. RIGIIIP1.ASl IC" 9(1. NONI 11 99711117RISPecily)
<br />464,
<br />41.41
<br />RISER SECONDARY CONTAINMLN T I. S%ILiA. U 4.I'1Rf:RGLASS RiRifiID PLASTIC 9n. NONE 99.OTIIIiR ISpeciQ l
<br />161
<br />FILL L- 1%1 I UNF.NTS INSTAL LED •IIALI
<br />1. SPfLI BUCKET 3. STRIKER PLATE BOTTOM PROTF. C'TOR • 4, ('ONTAfNNIFNT SI"M1IP
<br />Iq.,
<br />VII. TINDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRU('TION T'i K. ❑ L %ING[ R \YAI I ❑ 2, f)nl!RI F. WAI I Q'4, NO DISITNSFKS Q 9n
<br />41"
<br />-NONE.
<br />CONSTRIJ!'TICINSIATERI.4L ❑ J. STILL ❑ 4,FIBCRGLASS Q 10 RIGID MASTIC ❑ 90,0T)IC.R fS r.ifil
<br />wn.,
<br />VIII, CORROSION PROTECTION
<br />S I ELL COMPONLN I PRO I@ CI ION ❑„ SACRIFICIAL ANODES) Q.I IMPRESSED CURREN-I- El h. ISOLA I'IO.N
<br />--
<br />1X. APPLICANT SIGNATURE
<br />C '1VFI FICAT ION: I certify that this LSf System is compafible With (he haeardnue substance Mored and that the in rm•mation provided hereto is true, ae,u ra4r.
<br />nndin full rmnni(ancr )sigh b•eal euu!rrintrits.
<br />APPLICANT SIUNATURL
<br />�
<br />Z
<br />v'PurnxT.N,1MF(I'""Q
<br />npPLlcnrlrnn.�
<br />David H D) ars
<br />_C Directr r)t
<br />_ Real Fgtara Daya!nn(nent
<br />L'PC'F UST -IS- V2
<br />He,. (12120e7)
<br />
|