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i',U%; 1U: yy Zfj UNIFIED PROGRAM CONSOLIDATED FORM UNDFRGROUND STORAGE TANK 1 OPERATING PERMIT APPLICATION - TANK 1NFOR\1ATION'(It)nc1. 11r UST) TYPE OF ACTION (Check one item e or only. For an UST permanent closurremoval, complete only this section and Sec'- I%below) 41a ,1 .and ❑ L NEW PERh'lIT ❑ 3. RENEWAL I'EICh71T ❑• i. C'IIANCiE INFORMATION G. TEMPORARY UST CLOSURE 171 7. UST PERMANENT CLOSURE ON SITE X. LIST REMOVAL DATEUSTPERMANENIT.YCLOSED: aiba I DATE FXIb FIND UST DISCOVERED: L FACILITY INFORMATION FACILITY IDR (.Igex4g Use OnH) BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) I Costco Gasoline (Loc. No. 38) BUSINESS SITE ADDRESS city Ira 1616 E. Hammer Lane Stockton 11. TANK DESCRIPTION TANK IDS 41' LANK MANUFACTURER VI TANK C ONF10oRA'I"ION: THIS TANK IS 411 2 Containment Solutions 911. A STAND -:VANE TANK ❑ >. ONE INA CONIPARTMFN'I ED UNI I'. _ t :nvrl."o,. n.:, o' -1,,,ne punnmm In DATE UST SYSI"EM INS I"ALL.IiD 415 TANK CAPACITY IN GALLONS 4'6 NUMBER OP COMPARENI NTS IN MIi UN IT March 2004 20,000 1 111. TANK USE AND CONTENTS 'TANK USE R la. MO'IOli V E111CLF FUELING ❑ Ib. MARINA FUELING ❑ Ic. .AVIAT"ION FUELING 439 ❑ 3.CIIF,MICAL PRODUCT STORAGE ❑ 4. 1E\7ARD0US WASTE oadjdcs Weal OIII ❑ 5.F,NIF.ITGF.NC'YGF,NF]tATORFUF,LIHSC253N1,51c11 ❑ 6.01-HERGENERATOR FUEL ❑ 95. UNKNOWN ❑ 9n OTHER (SPeeiry): 4c11, CONTENTS PE'IROLA-I M: I] Ia. REGULAR L.NLEADED ❑ Ir, MIIIGRADE UNLEADED ❑ Ib. PREMIUMUNLE+M)ED n0 ❑ 3. DIESEL ❑ S. AFT FUEL ❑ 6. AVIATION GAS ❑ S. PETROLFUM 13LFND FL FI. ❑ 9. OT HER PETROI. FUM (S OW): 4Ula NON-11PTROI.FIAT ❑ 7. USFD (III. ❑ lo FTHANI"11 I L OTIIER NDN -PETROLEUM 15 silly: non IV. TANK CONSTRUCTION TYPE. OF TANK ❑I. SINGLE. WALL O2. DOUBLE WALL 095. UNKNOW IIT PRIMARY C'ON'LIINMENI' ❑ I. STEEL (0 3. FIBERGLASS ❑ 6.IN'I'LXN7LUL%DDLR J-14 ❑ 7. STEEL 1 INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTIIER (Spacify l: 444. SFCONDARY CONTAINMIiN T ❑ 1. SI 1+1 IN 3. FIBERGLASS ❑ 6. FXTERIOR MEMBRANE• LINER ❑ 7. JACKIiTED 445 ❑ 90. NONE ❑ 95.UNKNOW'❑ 99.UTHFR ISw,,II: 4451 ONTRFi ILI. PREVENTION M 1. AUDIBLE & VISUAL ALARMS 2. F3A1.1. FLOAT ❑ 3. FILL TURF S11UT-OFF VALVE -. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONS"FRUCTION ❑ 1. SINGLE -WALLED ■ 2. DOU13LE-WALLED 099. OTHER 41,1 - SYSTEM TYPE 11) I. PRESSURE ❑ 2. GRAVITY ❑ 3.CONVENTION.ALSUCTION ❑4.SAFLSUCIHON125CCR;26a600 11 Ifs I'RIMAkV CONTAINMENT [11, STRFI. L14. FIRFRULASS Q N. FLRXIBI.F ❑ I(1. RIGID Ill AS TIC' 101 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER{S cifv}: u4,, SECONDARY CONTAINMENT ❑ 1. STULL ❑ 4. FIBERGLASS O %. PLRXmLE ❑ 10. RIGID PLASTIC 4,,Ia ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.o11{ER I SInciTyr 464, I';I'I[O� TURBINECONTAINMEN'I"SL'NIF1)PE ❑I.SINGLEWALL 2. DOUBLE WALL ❑90. NONE 404E Vl. VENT, VAPOR RECOVERY (VR) AND RISER! FILL PIPE PIPING CONSTRUCTION %L%I' PRIMARYcoN"rAINMEN'I' ❑ 1sTPIi I- IN G. FIBERGLASS ❑ In KIUID PLAS DC ❑ 911, NONE ❑ W. OT HER ISiPccrtyl 464, 6 VEN'I'SECOWARI'C'DNTAINMGNI' ❑ I, S7 LRL R 4, FIBERGLASS ❑ In RIGID PLAS ❑ 911. NONE ❑ 99, OIHFRISpcdry) w4r 4Mu VR PRIMARY CONTAINMENT I. STLF7. • 4. FIBERGLASS ❑ ❑ ❑ IfI. RIGID ❑ 911. NONE ❑ o'1.OTHFR (SPecifyl 41d^- VRSECONDARI'CONTa1NMENT ❑ 1. STEEL OO 4. FIBERGLASS 0 ID. RIGID PLASTIC 0 9RNONE ❑ 9Q.OTIIERISpciRq u4h UAH VENT PIPING TRANSITION SUMP TYPE 1. SINGLE 3VALL LI 2. DOUBLE WALL IDI 90. NONE 464, RISER PRIMARY CONTAINMENT • 1. S'rl1.1:1. U 4. 1913LRGLASS ❑ 10. RIGID PLAS I'IC U 90. NONE ❑ 99. CII'1111R ISpccilyl r4, 4641 RISER SECONDARY CONT MNMENT I. STEEL El 4.IIBER-7-77I O. RIGID PLASTIC 91 90" NONE 0 99.OTHERISp,dJ1,I 117 blhl FILL C'O?fl'DSENTS INSTALLED ■ LSPILLBUCKF.T ■ 3. STRIKER PLAT F"'BOTTOM PROTF.0FOR • 4.CONLUNMENTSUMP 45w-. VII. IJNDFR DISPENSER CONTAINMENT (UDC) ('ONNI RF1 FION TYPE Q 1. SINGI F. 1V.41.1, ❑ 2- DOIIRI.E WAI I. ❑ 3. NO DISPENSERS ❑ 911. NONE. -69+ C'ONSTRUCTICINMATERIAL ❑ LSTEEL ❑ 4. FIBERGLASS IB Ili. IUGR) PLASTIC ❑ 99.OTHER(Swcils) VIII. CORROSION PROTECTION SIRELC'OMPONENYI' PROTEC'HON ❑ 2. SAC'RIFICIALANODE0 ❑ 4 IMPRESSEDCI-RRENI' t] 6,ISOLAI"ION -- IX. APPLICANT SIGNATURE (F.KTIFIC'ATION: 1 empty that this I SU s)strtn is compatible xith the hazardous substance stored and that the inrarmetion prnvided herein is true, accura1[. a11d in Ttdl rtn l han Cl'tint) le al rt' Vi ...vnr5, rn�,wr (--- NAME nrpucnNTIa 1hm) :M'PLICANT TITt. . David H Ro er Director of Real Estate Development M UPCF LIST -B- 112 Rev. (12/2007)