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} -Q� y L.. IED PROGRAM CONSOLIDATED FOiIJ2 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_I_of_6_ TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE .\ (specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(soreness FACILITY NAME or DBA-Doing Business As) 3. FACILITY m: ` COSTCO GASOLING LOC.NO.38 CA \p LOCATION WITHIN SITE(Optiooap aI I Z(o a37;;, L TANK DESCRIPTION �Q (A scaled plot plan with the Iocation of the UST system including buildings and landmarks shall be submitted m the local a ency.) �\ TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANKLj Yes ® No 47. CONTAINMENT SOLUTIONS If"Yes,"complete one page or eachcompen ani. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 036' NUMBER OF COMPARTMENTS 437 (YEAR/MO) _w&1+estiftl=M C, 20,000 1 ADDITIONAL DESCRIPTION( or kcal use only) 438. IL TANK CONTENTS TANK USE 4399' PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED [12. LEADED ❑5. JET FUEL (Ifchecked,complete Potrokum Type) ❑ Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Invemory page) CAS#(hom Hazardous Materials Inmmory page) *12' ❑ 4. HAZARDOUS WASTE 87 OCTANE 8006-61-9 (Iceludes Used Oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OFTANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM Us. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [j99. OTHER TANK MATERIAL-primary sank ❑1. BARESTEEL ®3. FBERGLASS/PLASTIC ❑5. CONCRETE 095.UNKNOWN dd4. (Cheekorehem only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP W/100%METHANOL TANK MATERIAL-secondary tank [3 1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBFRGLASS [39. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING Lj 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 19 6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑ I.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 45t. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT ® 1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE_ ®2.DROP TUBE ®2.BALL FLOAT ❑4.EXEMPT ®3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitirring programshall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) [11. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING [3 99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE FSTN1ATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidms.org Rev.02/INW