HomeMy WebLinkAbout3424 Sacramento_RedactedSAN LUIS OF3ISPO [FIRE DEPARTNIENT
APPLICATION FOR
Flammable Liquid Storaqe Tank Installation
LOCATION �'( 2`� `�1.CiZ7 DATE
BUSINESS OWNER V &Le_ ( 5 V(Utva1UADDRESS
r
PROPERTY OWNER
ADDRESS
INSTALLING CONTRACTOR IAr> A� J L ADDRESS
Description:
TYPE OF INSTALLATION: NEW ✓ REPLACEMENT
PLOT PLAN APPROVED Site must be inspected & plot plan
a prow prior to issuance of this application)_.
LIMIT OF PRK: Product Piping `� Tank Installation
P
TYPE OF PUMP SYSTEM eT45 iesw
TYPE OF PRODUCT PIPING TO BE USED: Plastic Protected Metal_
W
CATHODIC PROTECTION PROVIDED: Product Piping Tanks_
A
VENT PIPE: Diameter�Heightj ]/ Diameter of Fill Opening_
SIZE OF PRODUCT PIPING FROM TANK l if Ttb I'I�-
TANK INFORMATION:
CAPACITY:
DIMENSIONS:
SHELL THICKNESS:
AGE OF TANK:
UNDERWRITERS SERIAL NO.
TYPE OF FLAMMABLE LIQUID
Application By:
Approved:
TANK 41 TANK 42 TANK 43
4_4Vr-" it
ntra E or Authorized Agent
Lee M Schlobohm By:
Title
NOTE: Above approval subject to conditions listed below:
1. Contractor must notify Fire Department after tank has
been set and piping connected but prior to covering
tanks or backfilling(805/543-6046). Tanks shall be
set on and backfilled with at least six inches,and
covered with at least 36 inches of,noncorrosive,clean
sand well tamped in place.
2. Contractor must perform all work in compliance with
current provisions of the Municipal Code,the Fire
Prevention Code of the City of San Luis Obispo,and
NFPA ramphlet #30,"Flammable & Combustible Liquids
Code".
3. Contractor must provide and install tanks & product
piping of a type approved by the Fire Chief,preferably
A.D.Smith Co."Red Thread" fiberglass pipe,however gal-
vanized pipe,factory protected with epoxy or plastic
coating may be approved, Metallic tanks and/or piping
may be approved if provided with cathodic protection
approved by Fire Chief.
4. Joints utilizing metallic pipe must be protected with poly-
chem undercoating plus 3 wrappings of 10mil tape or 2
wrappings of 20 mil tape.
LMS/dr
9/74
'R ci , C) u
r�6-
STATE ID NUMBER
APP(T('ATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK
( ) 01 NEW PERMIT N ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE)
( 1 02 CONDITIONAL PERMIT I ) 06 AMENIJED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE)
nLIMPIP
NAMEICOR RATIOINDIVIDUAL OR Pu LIc AG.N TP(
UBLIC AGENCY ONLY
) 01 FED ( ) 02 STATE ( ) 03 LOCAL
STREET ADDPES TJTY ST/1TE 22P
5
aL4 V OL W"c
T T r A! TA T r V
FACILME
v� 5
ll0.
DEALER/FO
MAN/SUPERVISOR
_
STREET ADDRESS
NEAREST
ROSS STREET
CITY `
COUNTY
`
ZIP � /��
�-'
5
1 /
MAILING ADDRESS
CITYr I
STATE
1IP
Sl
1
p /.�R A CODE
TYPE OF BUSINESS
( l 01 GASOLINE
STATION (L.Y 02 OTHER
NUMBER OF CONTAINERS
1
RURAL AREAS ONLY TOWNSHIP
RANGE
SECTION
TTT 24 HOUR EMERGENCY CONTACT PERSON
4YS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAM; (LAST NT FIRST) AND PHONE W/AREA COD_
EtL�jLjD.
I
COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER
TV i)FCrRTPTT(1N
A. (X 01 TANK ( ) 04 OTHER: CONTAINER NUMBER
Jam' 4_r YEAR MFG: C. YEAR INSTALLED C1' I ) UNKNOWN
B. MANUFACTURER (IF APPROPRIATE): 7
D. CONTAINER CAPACITY: e r .0 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (1KQ 2 PRODUCT
F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE PIL ? (1,Y 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES):
( ) 01 UNLEADED ( ) 02 REGULAR ( 103 PREMIUM (Vr 04 DIESEL t ) 05 WASTE OIL ( ) 06 OTHER
., d /l\ITA TAICO rnMCTOIIrTTnW
A.
THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES (
) CM ("') UNKNOWN
B.
l 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (V) 02 NON -VAULTED (
) 03 UNKNOWN
C.
( )1 01 DOUBLE GALLED t V 02 SINGLE WALLED ( ) 03 LINEO
D.
() 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERG
( ) 06 ALUMINUM ( 3 07 STEEL CLAD ( ) OS BRONZE I ) 0 COMPOSITE
t 1 12 UNKNOWN ( ) 13 OTHER:
E t 1 OS CONCRETE
( ) 10 NON-METPLLIC _
turn this cor ;f t®
HSC04-070185 :� b � t Ja 1-4 _,4 k r ?? rA c a
I
STATE ID NUMBER
CONTAINER CONSTRUCTION
( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ) 05 GLASS LINING
(L-4 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER:
t 1 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE
(vl'06 TAR OR ASPHALT ( ) 09 OTHER:
VI PIPING
1. ABOVEGROUND PIPING: (
1 01 DOUBLE -WALLED PIPE
( ) 02
CONCRETE -LINED TRENCH (
) 03 GRAVITY
(CHECK APPROPRIATE BOX(ES)
( ) 04 PRESSURE y#�05
SUCTION
l ) 06 UNKNOWN ( 1 07
NONE
). UNDERGROUND PIPING: (
1 01 DOUBLE -WALLED PIPE
f 1 02
CONCRETE -LINED TRENCH (
) 03 GRAVITY
(CHECK APPROPRIATE BOX(ES)
(-) 04 PRESSURE (✓f 05
SUCTION
( ) 06 UNKNOWN ( ) 07
NONE
VII LEAK DETECTION
(Li✓ 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT
( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER:
VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS
IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIPED TO COMPLETE THIS SECTION
CURRENTLY
STORED
PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME)
STORED
(
) 01
( 1 02 [ ) 03 '
(
1 Ol
() 02 ( 1 03
I
! 01
( ) 02 { ) 03
(
1 01
( ) 02 ( 1 03
(
1 Ol
( ) 02 ( ) 03 I 1 LLl_
(
) 01
( ) 02 ( ) 03
(
101
()02 ()031111111 1111 11
(
) Ol
( ) 02 ( ) 03 1
O01
c)02 O03IIIIIIIIIIIII
(
1 01
( ) 02 ( ) 03
IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (tom 02 NO L
THIS FORE) HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, 10 THE BEST OF MY KNOWLEOGE,.J:S TRUE AND CORRECT.
PERSON ING (SIGNATURE) PHONE W/AR A CODE
FOR LOCAL AGENCY USE ONLY
ADMINISTRATING AGENCY (CITY CODE (COUNTY CODE
ICCNTACT PEPSON
PHONE W/AREA CODE
I
DATE OF LAST INSPECTION IIN COMPLIANCE I
PERMIT APPROVAL DATE TRANSACTION DATE (LOCAL PERMIT ID ((
( ) 01 YES ( ) 02 NO
HSC04-070185 PAGE 2
Application is
or on premises
SAN LUIS OBISPO _ l
APPLICATION FOR PERMIT TO AEMOVC-
UNDERGROUND HAZARDOUS MATERIALS STORAGE TANK
made by the undersigned for permit to removes tanks) in
PART I
OWNER: Name of Compa
Mailing Addre
Telephone: (
OPERATOR: Company: wJL-. az j CA.V_X)V`Contact:
Mailing Address:
Telephone: ( )
List previous owners and operators of the tank(s), if applicable:
DATE OWNERIOPERATOR
Attach a plot plan showing:
X Location of all tank(s) and piping and their secondary containment
Leak detection system
T Overfill protection system
X scale— aA X I10p4ve". Return this copy to
North arrow San Luis Obispo Fire Dept.
Property line
.P4_ Nearest intersection or road ,
Equipment summary
Existing equipment and equipment to be removed
Applicant gna ure Date
PART II
Date Tank Installed: ��'/'��% Volume of Tank (Gallons) . 3z> C i
Materials stored to tank:
DATE MATERIAL
�fi Y rcJlr.v /2,G25
�y%��'� HF-i ✓�� k/
Type of Primary Containment: ❑ Concrete ❑ Fiberglass P]- Steel
0 Fiberglass Coated Steel ❑ Other
Piping/Materials of Construction: W Steel ❑ Fiberglass ❑ Other
Type of Secondary Containment: ❑ Concrete [] Fiberglass ❑ Steel
❑ Fiberglass Coated Steel ❑ Other
Was any part of system cathodically protected?
If yes, which part(s)?
Describe leak detection system used, if any:
Describe overfill protection system used: A
What is approximate depth to groundwater? E
Basis of determination:
What is the final destination of the tank(s) for disposal?
Return this copy to
Spin Luis Obispo Fire Dent,
zofz _
II�I1'i�'���� IIIIIQ11 city of san Us owpo
II FIRE DEPARTMENT
748 Pismo Sleet . San Luis Obispo. CA 93401 . W51549 7380
March 11, 1986
Taco Works
3424 Sacramento
San Luis Obispo, CA 93401
TO: Underground Tank Owner and/or Operator
According to my records, as of this date, your underground tank
has not been registered with the State of California or this office.
Registration of the tanks is mandated by City ordinance No. 999,
which requires all underground tanks to be registered by March 1, 1986,
and compliance by September 1, 1986 for monitoring devices.
Contact me as soon as possible so I can assist you in compliance
with the Ordinance: 748 Pismo Street, Sar. Luis Obispo, 805/549-7380.
Very
�truly
yyyours,
v- —
R. K. Miller
Underground Tank Inspector
RKM:cb
RKM6