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• 0 BCnd10199 Tank1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK U OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) TYPE OF ACTION (Click one item only. For an UST pemlanent closure or removal, complete only (tis section and Sections L If, 111, IV, and IX below) 909 ❑ I. NEW PERMIT ❑ 3. RENEWAL PERMIT R i. CIIANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 0 7. UST PERMANENT CLOSURE ON SITE El R, UST REMOVAL DATE UST PERMANENTLY CLOSED: ""'a I DATE EXISTING LIST DISCOVERED: );96 1. FACILITY INFORMATION FACILITY [D H (Agvoc.31 Use (burl _ _ 1 BUSINESS \AME (Same as FACILITY NAME or DBA -Doing Business As) Costco Gasoline (Loc. No. 38) 13LISINL:SS SITL ADDR CSS I'" 1616 E. Hammer Lane CITY Ir'4 Stockton 11. TANK DESCRIPTION TANK IDn h� 11' �j� J`� 'fA 0 1 I%NIC\:%NIIFA(TURF.R 1'1 Containment Solutions 1'ANK CONFRAIRAI"ION: THIS TANK IS 414 QI.AST;ND-,V.ONII TA\'I( ❑? ONE INACOXIPAsIMIN;11)I\I1, _('n na. JP'�F.In1 rJi_ J. ,il. NUNJUL.R OL C'OMI' 1121 %II N I IN I'HI1.1\I'I'-- 1 DATE US'f SYSTEM INS1'ALLHD 415 March 2004 '1 ANK CAPACITY IN GALLONS J-1' 20.000 III. TANK USE AND CONTENTS TANK USE 0 Im MOI OR VEHICLE FEELING [I WMARIN.AFULLING ❑ Ic. AVIA I]ON FUELING -' ❑ 3.CIIENIICAL PRODUCT STORAGE. ❑ 4.IIAZ.ARDOUSWASTEIIua P,dcs Uscd Oil) ❑ 5. EMERGENCY GENERATOR FUEL [RSC,252SI not ❑ 6.OTIIERGENERATOR FUEL ❑ 95, UNKNOWN ❑ 99. OTHER (S,ciN): ' CONTENTS PL IROLEUVE I] ha REGULARUNLEADED ❑ Ic. MIDGRADL'UNLLADLO ❑ 11, PREMIUMUNLEADED ❑ 3. DIESEL ❑ 5. JET FUEL ❑ h. AVIATION GAS ❑ S. PETROLEUM BLEND FUha_ ❑ 9. OTHER PETROLEUM (S tail is 41,1. N'(.1N-PFTkO1.F.UNB 7, LISFb G11. ❑ W FTIIANOL El I I.OTHER NON -PETROLEUM (S wcif, I. u1m IV. TANK CONSTRUCTION TYPF. OF TANK Q LSINGLE. WALL Q 2. DOUBLE W'AL1. ❑ 95.INKNOWN 1r. PRIMARY CONTAINNIEN I' ❑ I,"EEL O 3. FIBERGLASS Q 6. IN'IIERNALHLADDLIt 111 ❑ -1. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.0TI ILR tsp,61,): SR CONDARY CON'FAI NNI FN I' ❑ I. S'I'rvE 91FIBERGLASS ❑ 6.F NFAIBRANI;LINER ❑ 7.JACKk fIfD II' ❑ 90. NUNS ❑ 9i, UNKNOWN ❑99.0'rHFR(S until: OVFRFILI. PREVENTION O 1. AUD1131 F. & VISUAL ALARMS IN 2. HALT. FI OAT ❑ 3, FII.I.TUBF SIIUr.OFF V:11 VF. Cl 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FRONI OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING C'ONS'TRUCTION 01. SINGLE -WALLED N 2. DOUBLE -WALLED 99. OTHER 4W SYSTEM TYPE (E I. PRESSURE U 2. GRAVITY ❑ 3.CONVENTIONALSUCTION Q4. SACC A!C71OS1`i1t'N en'.n�.ma ij 4<s PRIMARY CONTAINMENT ❑ I. STEFI. ❑ 4. F1HFR(JI.ASS Q R. FLEXIIII.F ff 10. Rlliln PI :1S I U' 4r7 ❑ 911. NONE ❑ 95.UNKNOWN ❑ 99.07AE11I5 61fNy 4w - SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. 171BERCLASS ❑• 8. FLFXIBLL Q 10. RIGID PLASTIC 41-I1, 0 90. NONE 0 9i. UNKNOWN ❑ 99. OTHER5 vLh I: 464` � PIPWGI'rURHIVE('ON'LAINAIENI' SUNIPJYPE ❑I.SINGLEWALL 2. DOUHI.E W':1LL Q90. NONE alta VI. VENT, VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY C'ONI'AINNIEN" I' ❑ 1, SPELL [19 d. FIBERGLASS ❑ In RIGID l'LASI'IC ❑ 90. NONE ❑ IN CIPHER ISpcc fvl 40'= 44"1 VLNT SECONDARY (ON 'FAINh1EN 1' ❑ 1. STEEL Q• 4. 19BLRGLASS ❑ 10 RIGID PEAS I ❑ 'Al. NONE Q 99. OIHI::It Sr,cfly) 4641 4o -m VR PRIMARY t'ONTAINMF.NT ❑ LSTEEI. Q 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90 NONE 0114r.(11111 It lspctifvl 4"9- 4M1loI VR SECONDARY CONTAINMENT I. STEEL CC 4. FIBERGLASS Lj 10. RIGID PLASTIC 90.NONE ❑ 99.OTIIERISpecify) 41.11 4 rIP.1 VENT PIPING TRANSITION SUNIP TYPE LI 1. SINGLE WALL 0 ->. DOUBLE WALL • 90. NONL 464 It ISI!R PRIMARY CONTAINNIENI' O ESTIiEI. U 4. 1 IFFRfrLAS.1' U 10. RIGID PLASHI U 90. NONE Q 99, 01 HI1R Upecdv) Jnll 41.10 RISKR SECONDARY CONTAINMENT 0 I. STEEL 0 4. FIBERGLASS U 10. RIGID PLASTIC 91 90. NONE 99.(rniFRispeclfy) 4^11 4r.1R1 FILL COMPONENTS INSTALLED • I. SPILL BUCKET 011 3. STRIKER PLATF.!BOTTONI PROTECTOR IN 4.CONTAMM INT SUNIP 411 - VII. TINDER DISPENSER CONTAINMENT (UDC) C'ONSTRLICTION TVPF O LNIMA EWAI.1, ❑ 2. DOUBLE WALL ❑ 3. NO MSPFNSFRS Q 90.NONF. m9� CONSTRICTION MATERIAL ❑ L NTI LL ❑ 4. FIBERGLASS 9 10. RIGID PLASTIC ❑ 99.OTIIER (Spavifv) U.9bc VIII. CORROSION PROTECTION S'EFELCOMPONEN'I' PRO'FECIION ❑ 2. SAC'RIFIC'IAL ANODEIS) ❑ 4 INIPRESSEDCURREN'I' [9 6. ISOLAI"ION IN. APPLICANT SIGNATURE CHR'fIFIC ATION: I certifv that this CST system is enmpalihle .cilli the hazardous substance slored and that the information prm'i(led herein is true. aeeuratc. and in fall com liance with le a c uirrnn•nts. APPLICANT SIUNAIURE PATE !� AN11('1\'I NAME (pial) p1 David H Ro ers APPLICANT Tl FIT. Director of Real Estate Development L1 PCF UST -B - 112 Rcv. (12!2007)