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IFIED PROGRAM CONSOLIDATED FO� TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1(� (Two pages per tank) Page_3 of 6 TYPE OFACTION D 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION (Clock ore item only) ❑ 6.TEMPoRARY TANK CLOSURE 430. ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8,TANK REMOVED BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY COSTCO GASOLING LOC.NO. 38 LOCATION WrMIN SITE(Ovtiona0 431. I.TANK DESCRIPTION (A scaled plot tart with the location of the UST system includingbuildings and landmarks shall be submitted to the local a enc .) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes No 434. 2 CONTAINMENT SOLUTIONS If"Yes."compete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. 'ff2tt=q) 20,000 1 ADDITIONAL DESCRIPTION(For Ioca1 use only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED (IFchecked,complete Petore ❑2. LEADED ❑5. JET FUELum Type) 016 PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MNGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (form Hazardous Materials Inrontory,page) "I. CAS#(from Hazardous Materials Invents 442. ❑ 4. HAZARDOUSWASTE Inventory,Page) (Inemdes Used On) 87 OCTANE 8006-61-9 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OFTANK ❑L SINGLE WAIL ❑3. SINGLE WALL WITH EXTERIOR (Check one item only) ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. MEMBRANE LINER 095. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑L HARE STEEL ®3. PIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE REINFORCED PLASTIC(FRP) W/100%METHANOL ❑99.OTHER: TANK MATERIAL-secondary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC 08. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN d45. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS 119. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑l0. COATED STEEL ❑5. CONCRETE TANK INTERIOR UNING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ,p�KN OWN 446. DATE INSTALLED 447. (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTIO (Check all that apply) ®1.SPILL CONTAINMENT N®1 ALARM EQUIPMENT: YEAR INSTALLED 452. ®2.DROP TUBE _ [13.FILL TUBE SHUT OFF VALVE ®3.STRIKER PLATE ®2.BALL FLOAT_ [14.EXEMPT IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453 (Check all that apply) IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check one item only) ❑LVISUAL(EXPoSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION 1:18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 1199. OTHER V.TANK CLOSURE INFORMATION It PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPI hwfwrc-b(I/99)-114 http://www.unidocs.org Rev.02/16ft t