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U -^IED PROGRAM CONSOLIDATED FORM <br /> ` TANKS <br /> UNDERG>< UND STORAGE TANKS - FAIRILITY <br /> 1_ 'b,� LI (One page per siteOPagelof-l- <br /> TYPE <br /> OF ACTION ®1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION <br /> ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same.,FACILITY NAME or DBA-Doing Busincrs As) 3. FACILITY <br /> COSTCO GASOLINE SITE NO.38. <br /> NEAREST CROSS STREET wt. FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT* <br /> WEST LANE/EAST HAMMER LANE ® L CORPORATION ❑5.COUNTY AGENCY* <br /> ItIISINI:SS L GAS S'1'A'I'If 1N 3,FAKM 5,('OMMERCIAI. 401. ❑2.INDIVIDUAL [16.STATE AGENCY* � <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> ER OF TANKS uW. <br /> TOTAL NUMBIs facility on Indian Reservation MI5. -If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT Sf1E or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 (new) ❑Yes ®No <br /> J <br /> II. PROPERTY OWNER INFORMATION 1ab\D <br /> PROPERTY OWNER NAME 407. PHONE 409 <br /> COSTCO WHOLESALE CORPORATION (425)323-6100 <br /> MAILING OR STREET ADDRESS <br /> 999 LAKE DRIVE 409. <br /> CITY 410. STATE 411. <br /> ZIP CODE 412 <br /> ISSAQUAH WA 98027 <br /> PROPERTY OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> COSTCO WHOLESALE CORPORATION (425)323-6100 <br /> MAILING OR STREET ADDRESS 416. <br /> 999 LAKE DRIVE <br /> CITY 4n. STATE ata. ZIP CODE 419. <br /> ISSAQUAH 98027 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 410. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 3 9 1 0 0 Call (916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®I.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL COVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LE'TT'ER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one bon to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless bon 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 cenif that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE FAPPLI � DATE 424, PHONE <br /> 5. <br /> ) <br /> NAME OF APPLI ring 426. TITLE OF AP ICANT fir 427. <br /> 1 -ie✓1 i// D C� j•`i /GhcC inn Cr <br /> STATE UST FACH_TrrY NUMBER(Agency ux only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ux q> 419. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-112 http://ww%.unidocs.org Rev.02/16100 <br />