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FIED PROGRAM CONSOLIDATED FO''`" I�z TANKS 0 UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages per tank) Page_I-of_6_ TYPE OF ACTION 21 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 Mason) (Specify,reason) ❑ B.TANK REMOVED Q BUSINESS NAME(Same as FACILITY NAMEor DBA-Doing Business As) 3. FACILITYID: COSTCO GASOLING LOC.NO.38 CAU LOCATION WITHIN SITE(Optimum) ^\0 I. 7 I.TANK DESCRIPTION , (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the'local nt .) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ageYes ® No 434. 1 Q / &q CONTAINMENT SOLUTIONS If"Yes:'complete am page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. 10/02(estimated) 20,000 1 ADDITIONAL DESCRIPTION(For tical use only) 438 II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE a4o. ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL Mchecked.compete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑It, MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(from Haumduus Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE 87 OCTANE 8006-61-9 (Includes Used Oil ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OFTANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary m� ❑ I. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCREPE ❑95.UNKNOWN 44a. (Checkom itemonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FIRE) W/100%METHANOL TANK MATERIAL-secondary tank ❑ 1. BARE STEEL 03. FIBERGLASS/PLASTIC 08. FRP COMPfIBLE W/100%METHANOL ❑93.UNKNOWN 445. (Check one item only) 02. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 09. FRPNON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED ❑99.OTHER (Check ane item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATEINSTALLED 449. PROTECTION PROTECTION [14.DAPRESSED CURRENT ❑99.OTHER IfA llcable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ® 1.SPILL CONTAINMENT ®1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE_ ®2.DROP TUBE ®2.BALL FLOAT [14.EXEMPT ®3.STRIKER PLATE W.TANK LEAK DETECTION (A description of the monitoring program shall 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) ❑1. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑ L VISUAL(SINGLE WALLIN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/ 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 UPCF hwfwn-b(1/99).1/4 http://www.unidocs.org Rev.02/16/110