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16'�IED PROGRAM CONSOLIDATED FO;t_ <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FAkAILITY <br /> -o5 (oaN (One page per site4P-gf <br /> TYPE OF ACTION 19 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED ,7 �Z, <br /> ❑6.TEMPORARY SITE CLOSURE 0/-' <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sam as FACILITY NAME or DBA-Doing BnCOMMERCIAL <br /> CILITY <br /> COSTCO GASOLINE SITE NO.38 U NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICTx 402.WEST LANE/EAST HAMMER LANE ® 1.CORPORATION ❑5.COUNTY AGENCY-BUSINESS IN 1.GAS STATION 3.FARM 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS 4o4. Is facility on 405. -If owner of UST is a public agency:tome of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the lank records) <br /> 3 (new) ❑Yes ®Nc <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE <br /> aos. <br /> COSTCO WHOLESALE CORPORATION (425)323-6100 <br /> MARLING OR STREET ADDRESS <br /> 999 LAKE DRIVE J09 <br /> CITY Oto. STATE 41t. ZIPCODE 412. <br /> ISSA UAH <br /> Q WA 98027 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> COSTCO WHOLESALE CORPORATION (425)323-6100 <br /> MAILING OR STREET ADDRESS 416 <br /> 999 LAKE DRIVE <br /> CITY an. 1 STATE 418. ZIP CODE <br /> ISSAQUAH 9 <br /> 98027 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 3 1 9 1 I 1 0 1 0 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: 422' <br /> [13.INSURANCE [16.EXEMPTION 119.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box m iMicam which address should be used for legal notifications and mailing. <br /> Legal mifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1,FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 421. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the inforrtlation provided heroin is we and accurate to the best of my knowledge. <br /> SIGNATURE FAPPLI T DATE -,-/ �ZQ72 azo. p��� 4Z7��bs35. <br /> NAME OF APPL- Tint) az6. TITLE OF AP [CANT /yam 423. <br /> 1 2✓!rI/ a CGlph <br /> STATE UST FACILTrY NUMBER(Agency use only) 428. q 1998 UPGRADE CERTIFICATE NUMBER e <br /> (See Dam Element 1,above. ( g my vse ly) azv. <br /> UPCF Hwfwrc-a(1/99)-112 http9/www.unidocs.otg Rev.02/16/00 <br />