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I I IONIFIED PROGRAM CONSOLIDATED TANKS $/ a UNDERGROUND STORAGE TANKS - TANK PAGE 1� (Two pages per tank) TYPE OF ACTION ® 1.NEW PERMIT Page_3_of_6 ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY TANK CLOSURE 430. ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reawn) (Swify reaum) BUSINESS NAME(Sam as FACILITY NAME or DBA-Doing III,Iss As) 3. FACILITY ID: ❑ S.TANK REMOVED COSTCO GASOLING LOC. NO.38 a5 1. 1-0 LOCATION WITHIN SITE(Op arof 431. I.TANK DESCRIPTION (A scaled plot Ian with the location of the UST system includin buildin sand landmarks shall be submitted to the local agency.) TANKID# _ 432. TANKMANUFACTURER 433. 2 //fD /S �p COMPARTMENTALIZED TANK ❑Yes No 434. CONTAINMENT SOLUTIONS If"Yes,^compkroore page for eachcompanmem, DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. (YEAR/MO) NUMBER OF COMPARTMENTS 10/02(estimated) 20 000 437. ADDITIONAL DESCRIPTION(For local ase only) 1 438. II.TANK CONTENTS TANK USE a39. PETROLEUM TYPE ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED 4 n (Kchecked,complete Peamkum Type) ❑2. LEADED ❑5. JET FUEL ❑ Ib. PREMIUM UNLEADED ❑3, DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ IC. MIDGRADE UNLEADED ❑4. GASOHOL ❑ 3. CHEMICAL PRODUCT 1199.OTHER: COMMON NAME (Wra Hazmdoas Matenals lrierory page) '141 CAS#(from Hewdue,Malarial,hroarno Palle) 412. ❑ 4. HAZARDOUS WASTE 87 OCTANE rYP s ) (Includes Used Oil) 8006-61-9 ❑ 95.UNKNOWN one III.TANK CONSTRUCTION (Check tem TYPE am ite, ❑1. SINGLE WALL 3. SINGLE WALL WITH EXTERIOR only) ❑ MEMBRANE LINER ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 413. ®2. DOUBLE WALL ❑4. SINGLE WALL INA VAULT [195. UNKNOWN TANK MATERIAL-primary hank 11 1. BARE STEEL ❑99. OTHER ®3. FIBERGLASS/PLASTIC 03.--CONCRETE ❑95.UNKNOWN (Clack,one item MATERIAL ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLAS$ 1' REINPoRCED PLASTIC(FRP) ❑S W 60➢c,MPETHANpL ❑��OTHER: TANK MATERIAL-secondary tank ❑1. BARESTEEL ®3. FIBERGLASS/PLASTIC ❑S. FRP COMF178LE W/I00%METHANOL (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑93.UNKNOWN 445. REINFORCED PLASTIC(FRP) ❑IO.FCOATED SOTEEODABLE JACKEf 1199.OTHER TANK INTERIOR LINING ❑ I.RUBBER LINED ❑5. CONCRETE OR COATING ❑2.ALKYD LINING ❑3.EPDXY LINING ❑3.GLASS LW LNG ❑95.UNKNOWN 446. DATE INSTALLED 447. (Check one item onl ) ❑4.PHENOLIC LINING ®fi.UNLINED ❑99.OTHER OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FlBERGLASS REINFORCED PLASTIC PROTECTION PROTECTION ❑4.BvIPRESSED CURRENT ❑95.UNKNOWN 448. DATE INSTALLED 449. (IfA licable) ❑2.SACRIFlGIAL ANODE ❑99.OTHER SPILL AND OVERFILL YEAR INSTALLED 450. TYP=IOVERFILL PROTECTIONEQUIPMENT: YEAR INSTALLED 432(Check all that apply) ®LSPILL CONTAINMENT®2.DROP TUBE M _ ❑3.FILL TUBE SHUT OFF VALVE ®3.STRIKER PLATE FLOAT_ [14.EXEMPT IV.TANK LEAK DETECTION IF SINGLE WALL TANK (A description of the monitorin rogram shall be submitted to the local a nc .) (Check all that apply)1 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 4M.. I. VISUAL(EXPOSED PORTION ONLY) 115.MANUAL TANK GAUGING MTG (Check one item only) ( ) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER [14- STATISTICAL INVENTORY RECONCILIATION ❑3.MANUAL MONITORING ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING 1199. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. FS77MA I ED QUANTITY OF SUBSTANCE REI 436. TANK FILLED WITH INERT MATERIAL. gallons ° 437 ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.07/16/00