HomeMy WebLinkAbout2GUARDTAIU
Warranty Gorporation
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407 McAlpine Street - P.O. Box 5068 -Avoca, PA 18641-0068
570414-8877 - I-800482-7357 - Fax: 570414-7883
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SAN LUIS OBISPO CITY
APPLICATION FOR PERIIIT TO ABANDON/CLOSE
UNDERGROUND HAZARDOUS MATTRIALS STORAGE TANK
Application is hereby made by the undersigned for permit to abandon tank(s) in
or on premises at:
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OWNER: Name of Company ,ftb D, / 144 "4L Contact:
Ma i'l i ng Address :z
Tel ep hone: VA5T f/3-73 ra
0PERAT0R: Company:2-)alzZl"-t Contact:
l4ailing Address:
Tel ephone: (
List previour'o"n.rs and operators of the tank(s), if applicable:
DATE OI,JNER/ O PERATOR
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Attach a plot pian showing:
Location of all tank(s) and piping and their secondary containment
Leak detection system
0verfill protection system
Scal e
North arrow
Property I ine
Nearest intersection or nc
Equipment surmary
Exlstlng equipment and equ
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ipment to be
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ved
4
PART II
Date Tank Installed:
Materials stored in tank:
DATE
L
tl e
HATER I AL
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Volume of Tank (Caltons)
or
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Gr Qiasf.o)-
Type of Primary Containment:' 11
Piping/l'laterial s o f Construction:
Type of Secondary Containment:
Conc rete ts Fi bers'lass E Steel
Fi berg'lass Coated Steel t] Other
& steel ,W Fi be rs1 ass n other
n conmete t] Fi bergl;ss I stee]
n Fiberglass Coated Steel t] Other
Has any part of system cathodjcally p rotected? [I,€
If yes, which pa rt(s)?
Describe leak detection system used, if any no
)
Describe overfill protection system used:
What is approximate depth to groundwater?
ij Basis of determination: -
l,lh t is the flnal destlnation of the tank(s)
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-ry[ffiruil|lglltlillililil Gty oF san Lurs onrspo
ni:,+..,.;'.ffi:.lp,,, i,4;1iiiil e;r" Deporiment . 748 Pismo St.. Son Luis Obispo,Co.93401 o 549-738Opbrrtn.it lrecnrined
ADDRESS, /37/ Moufnze'ATE:5 6 gc
C. Dutnprz*it ro IS REOUIRED TO OBTAIN A PERMIT
TO MAINTAIN,, STORE, USE OR HANDLE MATERIALS, OR TO CONDUCT PROCESSES, OR
TO NSTALL EOU PMENT AS D ESCR IB BEL
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THE PERMIT MAY BE OBTAINED FROM THE FINANCE DEPARTMENT AT 990 PALM ST.,
SAN LUIS OBISPO, CA 93401 OR BY RETURNING THE ENCLOSED ENVELOPE WITH A
CHECK TO THE CITY OF SAN LUIS OBISPO IN THE AMOUNT OF:
5 $ 7O. AA PaYable within 3l@-
PER I W ILL
BY:I.D. N O/
VAL ID UNT IL Qt c.acA_- s/d/f6
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Permittee
ryyruUflilryffiU clty oF san Lurs oBrspo
11":-l=%* ilmi'$if rir" Deporimen t c 748 pismo sr.. son Luis obispo,co.93401 . s49-238o
IDbrDiltit rpectrrLrred
ADDRESS:/ 3 7t Mc,u'fnzr-5 6 ge
C Daa'tprzlti-t ro IS REOUIRED TO OBTAIN A PERMIT
T,O MAINTAIN, STORE, USE OR HANDLE MATERIALS, OR TO CONDUCT PROCESSES, OR
TO NSTALL EOU PMENT AS D ESCR I B 0
o
THE PERMIT MAY BE OBTAINED FROM THE FINANCE DEPARTMENT AT 990 PALM ST.,
SAN LUIS OBISPO, CA 9340I OR BY RETURNING THE ENCLOSED ENVELOPE WITH A
CHECK TO THE CITY OF SAN LUIS OBISPO IN THE AMOUNT OF:
5 s 70. 0 0 Pavable with'in 3€@s=
Qt C+c.a__, s/d/ K{
PER W ILL VAL ID UNT IL
O/OsL BY:
ATE:
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