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[anK4 N7&IFIED PROGRAM CONSOLIDATED FOil4I UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UsT) TYPE OF ACTION (Check me item only. For an UST permanent closure or removal,complete only this section and Sections I,H,III,IV,and DI below) aJo ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑9 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410' DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same es FACILITY NAME m DBA-Doing Business As) 1 Costco Gasoline(Loc. No.38) BUSINESS SITE ADDRESS 103 CITY 104 1616 E.Hammer Lane Stockton H.TANK DESCRIPTION TANK ID#n 3�7 �V 1 j`J 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 f fl. 0 1.A STAND-ALONE TANK 4 Containment Solutions ❑2.ONE INACOMPARTMENTED UNIT. cbnyefe for e.6 tmffi.,mit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 43/ TBD 1,500 1 M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lvdvde.Uwd Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN Q 99.OTHER (Specify): Fuel Additive 43% CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ IC.MIDGRADEUNL.HADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ■ 9.OTHER PETROLEUM (Specify):LUBRIZOL 9888 Fuel Additive a4% NON-PETROLEUM:❑ 7.USED OH. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL E 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+R41TRNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 449a SECONDARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER S cci 445. OVERFILL PREVENTION L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FH1.TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGL&WALLED N 2.DOUBL&WALLED ❑99.OTHER 460 SYSTEM TYPE ■ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 42636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL E 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 444 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specity): 464. SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGMURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464• 464.1 VENT SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464Fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 4648 46411 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 461h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT I'] 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464'1 464' RISER SECONDARY CONTAINMENT ❑ 1.STEEL ■ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL-COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451.-. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ■ 90.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691" VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT I] 6.ISOLATION 448' IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and In full compliance th legal requirements. APPLICANT SIGNATURE< f� r,- � D. 00. S DATE % a70. I 6/WJo-'r' )� � l3 APPLICANT NAME(print) 671' APPLICANTTTILE ave. David H Ro ers Director of Real Estate Development UPCF UST-B-1/2 Rev.(12/2007)