Laserfiche WebLink
l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK \ '"• ! I <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION .2,36-- <br /> tont lilrnt licr facility) <br /> IYI'I OF At`)ION ® L NF1'I'LRMII ❑ S.C IIAN(T.OF INFORn1A7'ION 7. ' 44, <br /> it'Ik-4.mc uem wdvl ❑ 1 L1UlANEKF FACILITY CLOY IRI: <br /> ❑ 3.RI NLWAI I'LRMIT ❑ 6,1EMPORARY i ACILITY CI.OSI.IRG ❑ 9-TRANSFFIt PERMIT <br /> 1. FACILITY INFORMATION <br /> 1 OTAL NI•NIRER OF PS I a A F FACILITY Y +'1+ 1 <br /> 3 fAcn.rn'1D a <br /> t.lge,+cr!vv Onh) <br /> fit-SINESS NANII.(.i,mw 1.1111.111'\\,N f u Da.l D.nna Du,wc .{, <br /> Costco Gasoline <br /> 11USIN'FSS SI I L ADDRESS lo; CITV l t , <br /> 322 East Harney Lane Lodi <br /> FAC ILITY TYPE ® I MOTOR VEHICLE FUELING ❑ 2 1 ULL DISTRIBUTION Is the facility locaicd on Indian Reurt ation of M` <br /> 3.FARM 4.PROCr:SSOR Q 6.(AT IFR Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPER 11'Old YFFt NAy11` 401 1 PHONE I-IN <br /> Costco Wholesale ( 425 ) 313-8100 <br /> MAILING ADDRESS <br /> yr, <br /> 999 Lake Drive <br /> CII Y +1" STATE 411 1 ZIP CODL u' <br /> Issaquah WA 98027 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPFRAIUR NAMI +'A-1 YIIONE 17a•] <br /> Costco Wholesale 425 313-8100 <br /> NIAIL.INO ADDRESS I_x <br /> 999 Lake Drive <br /> ('I IT ,:a+ STATE +''-s` Z111 CODE <br /> - Issaquah WA 98027 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NA\71. 1t+ PHONE Itc <br /> Costco Wholesale 425 ) 313-8100 <br /> NAILING,ADDRFtiti Ith <br /> 999 Lake Drive <br /> CITY 01 STATE als ZIPCODE• n•• <br /> Issaquah WA 98027 <br /> OWNLR TYPE ❑ 4 LOCAL AGENCYJASTRIC F ❑ S COUNTY ACFNC'Y ❑ f+.STATE AGENCY <br /> ❑ 7 FLDERAL AGENCY ® 8.NON-GOVEIMIENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 41- n 1 3 1 9 1 1 1 0 1 0 011 the Stale Board of FilnaliMion.Ful Tax Di%'16Ion.iftherc arc yucairnl1 ^1 <br /> V1. PERMIT HOLDER INFORMATION <br /> kwe purnul:utd send Ictal n.aificalions and mm1ines u,: ❑ 1 FACILITY OWNER ❑ 4.1ANK OPERAI OR <br /> 10 1.TANK OWNER ❑ S.I-ACIIJr%*OI'f,RXI OR <br /> SUPERVISOR OF DIVISION.SLC 11ON.OR OFFILI (Rcgturcd Fix Public Acencics Only) <br /> V1I.APPLICANT SIGNATURE <br /> CERTIFICATION: I certin•that the information ro%lded herein is true accurate and In full compliance with legal requirements. <br /> APPLICANT SIGNATURE / DATE -04. PHONE + <br /> 06/28/10 425 313-8100 <br /> APPLICANT NAMI.(prial) ha APPLICANT TITLE 1+1 <br /> Dennis Bock Environmental Compliance Manacler <br /> UPC'F L:ST-A Rr+•.(1212007) <br /> 14573.007.pdf <br />