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v ..i BCE #10199 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION —FACILITY INFORMATION <br /> (One lornl per t"auilil9) <br /> till <br /> TYPE OF ACTION C1 LNEWPERMIT FOI 5.CHANGE OF INFORNLATION [17-PERNIANENT FACILITY CLOSURE <br /> I('h<a uia•urm only I <br /> ❑ 3.RF.N F:\1'AI.PERMIT ❑ ft. TEMPORARY FACILITY CLOSURE 9.TRANSFIiR 1'fKM11' <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF US fs A f FAC'11.1'I'YM TJT1 <br /> +"+ FACILITY IUk <br /> 3(Existing)and 1 (Proposed)-4 Total r,li<•;,<r v.r OnR r <br /> HUSINFSS\AMH(S,.--1 noun >n,u.,Dirt <br /> Costco Gasoline(Loc.No.38) _ <br /> BUSINESS SI FL ADDRESS I"s C1 Ty pu <br /> 1616 E. Hammer Lane Stockton <br /> m a< <br /> FA('II I'fY'1'1'PIL MOTOR VP.HI('Lli PUI'I IN(i ❑ J. PUP.I.DISTRIBUTION In Thr ISOihly bWian RorrvaH,m w <br /> 3.FARM Ej J.PROCESSOR L.OTHER Ti ast lander ❑Yes N No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME +a' PHONE J0" <br /> Costco Wholesale,Attention: Licensing 425 313.8100 <br /> MAILING ADDRESS +� <br /> P.O.Box 35005 <br /> (TTY °D STATE +t' ZIYCODE <br /> Seattle Washington 98124 <br /> III. TANK OPERATOR INFORMATION <br /> LANK OI'FRAFOR NAMF. "" PHONE <br /> Dennis Bock,Costco Wholesale ( 425 ) 313.8100 <br /> MAILING:AODRLSS <br /> 999 Lake Drive <br /> CI.I.Y +"-+ SAT@ +:vs ZIP CODI. +: <br /> Issaquah Washington 98027 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME +,+. PHONE +< <br /> Costco Wholesale,Attention: Licensing ( 425 ) 313-8100 <br /> M:AJUNH:ADDRESS "^ <br /> P.O.Box 35005 <br /> (:fl'Y u' j SI':A'IE nx ZIP CODE ". <br /> Seattle Washington 98124 <br /> 0\1'\IIK IYPL: ❑ a,LO('ALA(iL NC'Y%DISI"RWr ❑ 5 ('01 N'IY A(ili\CY ❑ 6,SPATE A6LNCY <br /> ❑ 7.FEDERAL AGENCY M KNON GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)IIQ 44- 10 13 19 11 O O 1 Call the State Board of Equalir dim.Fltal Tax Division.if ihcm we quesliti t. <br /> VI. PERMIT HOLDER INFORMATION <br /> Is.ne prnnn mut vent legal nmilic,ituxn and rn;ulings m: ❑ 1 FA('il.l"I'Y(1\\•'VFK ❑ -I.I'A' UI'E:ItA 1'0 1( <br /> 0 3.TANK OWNER ❑ S.FACLITYOPERATOR <br /> SUPERVISOR OF DIVISION,SF('TION.OR OFFI('E IRvquocd For Fttbhc Agcocivs OnM <br /> VII.APPLICANT SIGNATURE <br /> C'LRTIFICATION: I certify that the information prorided herein is true.accurate•and in full compliance with legal requirements. <br /> APPLICANTSIG. U/)TC 1'+ 1'110]1? <br /> fizz 425 313.8100 <br /> V'I'1 ( AN l-NA. 'Iptm) :APPLICANT IFLE <br /> David H Rogers Director of Real Estate Development <br /> 1 I•f1 ISI-A Rev.(1212Ua7I <br />