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i <br />0 g,)/qI <br />UPCF UST -A Rev. (12121)(17) <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />er <br />UNDERGROUND STORAGE TANK <br />OPERATING <br />PERMIT APPLICATION- FACILITY INFORMATION IL/I`�� <br />(One fora/ m racdity) <br />TYPE OF ACTION ❑ I. NEW PERMIT <br />] 5.CHANGEOFIN'FORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />+ua <br />1C1ark ow itnn mlyI <br />❑ }. RF.NElV.41. PERMIT [1 !,. TEMPORARY FACILITY CLOSURE ❑ 9, TRANSFER PERMIT <br />L FACILITY INFORMATION kqk I <br />TOTALN(Al H FR OF(JSTs AT EACH.]']')' <br />FACILITY IH rx <br />3 (Existing) and 1 (Proposed) = 4 Total <br />RlJ$INESS S:1MF. fs.:n:_„1cu'u ltr a:,,o- ,, nun <br />urmp w..m.., n:l <br />Costco Gasoline (Loc. No. 38) <br />M SINLSS SI1"E ADDRESS <br />1113 <br />CI IN <br />1616 E. Hammer Lane <br />Stockton <br />FAC H-11 Y IYPI' ■ 1, MOTOR VEHICLE <br />FUI:L ING ❑ 2. FUEL DIS"I RIBU"I1ON 1113 <br />------------- ----- <br />Is the Lmilitq Iocaled mt hulian Rescrr;uinn or <br />-9i <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ L. OTHER <br />Tout hands? ❑ Ycs N No <br />II. PROPERTY OWNER INFORMATION <br />PROPER TY OWNER NAME <br />-u' <br />PHONE, <br />401). <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313.8100 <br />%I;YII.INO ADDRESS <br />1 <br />P.O. Box 35005 <br />( I I Y <br />111) <br />STATE +" <br />ZIP CODE ---- <br />41e <br />Seattle <br />Washington <br />98124 <br />III. TANK OPERATOR INFORMATION <br />F\NKO'FRATORNAMF <br />PHONE. <br />4242 <br />Dennis Back, Costco Wholesale <br />( 425 ) 313-8100 <br />,MAILING ADORLSS <br />a_r.l <br />999 Lake Drive <br />CITY <br />+'"-+ STATES ZIP CORP. —_— <br />'=+-'• <br />Issaquah <br />Washington 198027 <br />IV, TANK OWNER INFORMATION <br />TANK OWNER NAN'IE <br />n+ <br />PHONE <br />1)5, <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313-8100 <br />MAILING ADDRESS <br />11e <br />P.O. Box 35005 <br />CITY <br />i¢ <br />STATE <br />CUDE. <br />. <br />Seattle <br />Washington <br />98124 <br />OWNER TYPE: ❑ 4. LOCAL ACLNCY?DItifRK I ❑ 5. C'OG\r :AOLAC'Y ❑ 6 STA 1'G AGIiNC'Y' <br />+'1' <br />❑ T. FEDERAL AGENCY N 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 10 3 9 11 <br />10 0 1 Call the Slate Board of Equalization. Furl Tax Division, ifthereare questions. <br />VI. PERMIT HOLDER INFORMATION <br />Is.<ue pmnn anel sant legal nntilu-wions and rnuilirn_�s <br />to: ❑ I FACILITYq\4'1FIt ❑ 4. TANK OPERATOR <br />❑i i. TANK OWNER ❑ 5. FACILI7"Y OPERATOR <br />SUI'EItV15ON OF DIVISION, SECTION, Olt UFF1C'F. IRrquird For Public :Agcnelcr Only) <br />«n; <br />VII. APPLICANT SIGNATURE <br />CE1111F1CATION: I ce -65, that the inAormiation <br />pirovided herein is <br />Ime. accurate, and in 1`1111 Com Bance With legal IT uirenlCnts. <br />%� <br />PHONE <br />+=� <br />I'd Q(i <br />( 425 ) 313-8100 <br />APPLIC'ANI NA, F: (Priet) <br />--' <br />AF'I'LIC'ANT' fTLE <br />David H Rogers <br />Director of Real Estate Development <br />UPCF UST -A Rev. (12121)(17) <br />