BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

U ED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - F .ILITY t-a(,4 (One page per site Page L of_I_ TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) [18.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 0 L FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILrry NAME or DBA-Doing Business An 3. FACILITY O COSTCO GASOLINE SITE N0.38 1, I a AD oi7a NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. WEST LANE/EAST HAMMER LANE ® 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* 12, 'v TOTAL NUMBER OF TANKS Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) 3(new) ❑Yes ®No U IL PROPERTY OWNER INFORMATION `ab� PROPERTY OWNER NAME 407. PHONE 4011. COSTCO WHOLESALE CORPORATION (425)323-6100 MAILING OR STREET ADDRESS 409. 999 LAKE DRIVE CITY 410. 1 STATE 411. ZIPCODE 41Z ISSAQUAH WA 98027 PROPERTY OWNER TYPE ® 1.CORPORATION 0 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414, PHONE 415. COSTCO WHOLESALE CORPORATION (425)323-6100 MAILING OR STREET ADDRESS 415. 999 LAKE DRIVE CITY 417. 1 STATE 418. ZIP CODE 419. ISSAQUAH 98027 TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 0 3 1 9 1 1 1 0 1 0 1 Call(916)322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑g.STATE FUND&CFO LEITER ❑99.OTHER: [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. ata. PHONE 425. SIGNATURE FAPPLI T DATE ��/�� (4Z5)IV-;7A5-3 NAME OF APPS rint) 426. TITLE OF APjyICANT 427. � ✓//I/ o G� �i �(!f'/CC /��llrl� Cr STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use ly) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 hltpz//www.unidocs.org Rev.02/16/00