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�' UNIPIED PROGRAM CONSOLIDATED PORV•I <br />1 ��, <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION— FACILITY INFORMATION lirn( <br />p/��)i <br />(One toer facility) <br />TYPE OF ACTION ❑ I. NEW PLRA'lIT ■❑ 5. CHAN-GEOF INFOR\IATION ❑ 7. PERMANENT FACILITY CLOSURE +au' <br />10x), one item onl}I ,3. R6NRWAI. PERMIT <br />❑ ❑ G. TEMPORARY FACILITY CLOSURE ❑ 9.'FRANSFFR PERMIT <br />I. FACILITY INFORMATION <br />TOTAI.MAIDER OF USrsA l F:ACIIJI "" FACILITY IDA � <br />3 (Existing) and 1 (Proposed) = 4 Total Nge er:r use o..1,; — — 7 p C <br />J <br />f11.1$INESS S:IMF. Is:�.::a ru'n rn'aam,•, mtn n,.�,c tl,,.;,,.... 7)a , <br />Costco Gasoline (Loc. No. 38) <br />BUSINESS SITL ADDRLSS 113 <br />C11 Ir" <br />1616 E. Hammer Lane <br />Stockton <br />FACIL I"I"Y TYPE. ■ I, MOTORVI[HIC'LEI:UI;L.ING <br />❑ ❑ 2. I�UIiL UIS'I'R 113CI'fIUN <br />Is I}te lat'i Ii1J' Iocalv-d m, Lilian Rrstrv;nicn or <br />❑ J. FARM Cl d. PROCESSOR ❑ G. OTH ER <br />Tn,st lands? ❑ Ycs ®No <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME +a' <br />PHONE uix. <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313.8100 <br />NIAILINO ADDRESS :uv. <br />P.O. Box 35005 <br />(fly )m <br />STA'fr J11 <br />ZIP CODE <br />Seattle <br />Washington <br />98124 <br />III. TANK OPERATOR INFORMATION <br />LANK OPERATOR NA\IF +:a; <br />PHON F.'_*-+ <br />Dennis Bock, Costco Wholesale <br />( 425 ) 313.8100 <br />MAIL. TNG ADDRESS <br />999 Lake Drive <br />L'1'rY 'a-' <br />STA 'fli':'"; <br />------------ - <br />Issaquah <br />Wash ington <br />98027 <br />IV. TANK OWNER INFORNIATION <br />'TANK OWNER NAME +1+, <br />PHONE- a. <br />Costco Wholesale, Attention: Licensing <br />( 425 ) 313-8100 <br />MAI1-IND ADDRrSS au.. <br />P.O. Box 35005 <br />CITY ul. <br />STATE +l>; <br />ZIP CODE <br />Seattle <br />Washington <br />98124 <br />OWN LR'I'YP EI ❑ q. LOCAL ACENC}VL)151'RICT ❑ 3, (.UUN'I'Y AGE'.N'C'Y ❑ G. S'I A'I'L A(ili.NCY <br />❑ 7. FEDERAL AGENCY 9 N. NO\-GOVFRNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />j K)HQ 4- 10 3 9 11 0 0 Call the State Raatd of F.quoli>artnn. Fuel Tax Div isinn, if there art questions. <br />Vl. PERMIT HOLDER INFORAIATION <br />,, <br />Isar pzunit and send le_ral nutillerrtions and nutilinL�ao: ❑ 1. FACILITY' OWNER 4. TANK OPERATOR <br />■❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />xm. <br />SUPERVISQR OF DIVISION, SECTION, OR UFFICF IRcquircd Por Public Ac..n:; Only) <br />VIL APPLICANT SIGNATURE <br />CLRI IFICATION: I Cel'tlfy that (lie 11 rmat1011 providttl herein Is (rue, accurate, and in hall con] )hanee 1SIth Icon) requirements. <br />AR Tslc. <br />-T,,; <br />� <br />% <br />425 ) 313.8100 <br />:\Ft'L'II':\NI'N:1, Elpllnn +m <br />APPLICANTPILE +=' <br />David H Rogers <br />Director of Real Estate Development <br />1,l CP UST -A Rev. (1212007) <br />