HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_2478_001ctry or
san'Lurs oBrspo PERMIT
FIRE DEPARTMENT - 2160 Santa Barbara Avenue, San Luis Obispo, CA 93401-5240,805/781-7380
"Courtesy & Service"
ADDRESS:43r'5 S, t'iigur:rn-DATE lvrarch 115, :1003
C;.:rrrLl-..1 BulJ-cifurg Co. f or PG&li Has permission to maintain, store, use or
handle materials, or to conduct processes, or to install equipment as described below
ld*)movr: .lir.dt 5110--gal-l-on wii$te D.ot.or oi.l. ftr.r.rk
(taiik. to be r:epl,;rced ai- u lal:er da-i:*l)
All requirements shall be per the Uniform Fire Code and its standard.
Date of Event and/or expiration:it{ay 30, ?003 Permit Fee:$b1;Z.t't{}
l.D. Number:
i(e rr,v y-l <+ ,1:r,r r 1.:r j"L"i Corli'cl":Li':t i:,lr'
Whiterlellow - Fire Department Pink - Perminee Goldenrod - Finance D€partment
By
The Prynt€rs - 9/99 - 71 - City-Permit
SS
Date Tank Installed Volumc in Gallons
B. Water to Facility Provided by:Ct atr 4anl ittlI
Depth to Groundwater: Basis of Determination:
C. Tank Removal Contractor: Cf+r<raou'_ buttpt^k, 6"Cal. License No b56 3
Address 0h Vtcro * l\r'a 4Lo +a 4+ I - 3153
3. ?-
Proposed Starting Date:
Telephone:
F**
LaOb Proposed ComPletion DaterL 14 Loo
Insurer: 9tme Fr.ruo
D. Chemical Compositiou of Materials Stored:
Tank #
I
Chemical (cornmon name Dates Stored
to
Size PreviousChernical
t-It
E. Final Destination of Tank:
Address Telephone
San Luis Obispo City Fire Department Permit No.
2160 Santa Barbara Avenue, San Luis Obispo CA 93401 Application Date
805/781-7380 No. of Tanks to be Removed I
Permt'L Fee- $btz,oo
APPLICATION F'OR PERMTT I'OR TEMPORARY OR PERMANENT
CLOSIJRE/REMOVAL OF UNDERGROT.JND
HAZARDOUS SUBSTANCES STORAGE FACILITY
Type of Application (Fill out one application per facility)
[] Temporary Closure []PernunentClosure [] Removal
A. FacilityName: ?G+t- - Snor Lvw 9rzir?o Spxwtee_{egW
Address: 4zZO €,lltauel-a 9r,Contact Person: R ICIU t5
Telephone (days): 595 - bzqt (nights)54b - 4b0 4
Owncr:?a 4e 5e5- bz93
Address:
Operator
Address:
44b *t6oepa *T,zip tl')+o I
?aqz Telepfrone:5 95 - L7e3
4oG *r;u*-^ 3r I3+D (
Date Tank Instalied:Volumc in Gallons
B. Water to Facility Provided by: C trv otr 5aru Lye Drq,qpo
Depth to Groundwater:Basis of Determination:
C. Tank Removal Contractor:(a Cal. License No. 1 55G73
Address: tb7t V,q,€qLa 40 Telephone: 4+l - 3"153tro4 W
Proposed Starting Date: ArKtL 14.1m)Proposed Completion Date:'Lao
Insurer: 5t*te Ferso
D. Chemical Composition of Materials Stored:
Tank # Chemical (common Dates Stored
to
Size Previous Chernical
t-2a rl
E. Final Destination of Tank:
Address Telephone
Feb 1A 03 O9:58a san- LUl
)
ft
-7 Leak detection sY steln
T Ov erfill protection systern--y -Scate-7-North arrow
-7-PropertY line
TNearest intersection or road
H
F previous owners/operators of tauk(s) if APplicable:
Date
G. Attach Plot Plan Showing:
Location of all tank(s) and piping and their secondary containment
--", Equipment summary
iiliiil;ild;;niu'a equipment to be rernoved
Iial:Ii:-iTu",illiii','""" rrlsteet 1$piuergtas
Piping/Materials of Construction:
fvfs.J"r []Fiberglass []other
s Coated Steel [ ] Other
[ ] Steel
,'
l{pbergtas6,Coatecl Steel [ ] Other
catho dicallY Protected ? t"lo
used,any:'J
Type of SecondarY Containment:
[] Concrete [] Fiberglass
I. Was anY
If
J. Describe
0 fopllkl '
\IL U
K. Describe overfill protection system used: 5 vur
THIS FORM HAS BEEN COMPLETED T]NDER PENALTY OF PERTARY AND TO THE BEST
tii uv KNywLEDGE IS T'RvE AND conpacr'
3^v
Name
FIRE DEPARTMENT USE ONLY
Describe Method for Retrieving Samples:
Samples Will be AnalYzed For:
Laboratory That Will Perform Analysis:
Address
H:FDP269-6195
TelePhone
County of San Luis Obispo
MEMORANDUM
To , Sp**n-aa-,
(/
r,q)artment of Public Health
Date ,l 2{
Frorn
Sun;rrcr i
hrr"l"rJr/ tr t/'- ,"^At'L/'t'*
C"r"t^t,fulhrya,
Uuf*'uaolt:6tJ J
Jr^d-l! fa',Jw
ttlJ4-
(;a7fl t,I C.el t-U (tl'
+K
&,*
Conl. Lic. No.478335
General Eng. Lic.
C61 Specialty
. General Construclion
Under Ground.
. Fuel Systems
FRED RODNEY
CqgE{'uction
Supf- \ndent AN LUI
ION FO
{AZARD
fiStJ:l'?3il re premi ses at
Visalia, CA 93279
tJ l SPO COUNTY /
ERHIT T0 C0NSTRU, rl
MATERIALS STORAGE TANKCRISP
CONSTRUCTION
COMPANY
5U
RP
OUS
Tank Testing
&
Service
r Existing Tank tr Transferr of Ownership
4?2-<-?,n,r(h llraitEpA
PART I
OI,INER
OPERATOR:
Company:
Compa ny Paerrt e 0,rs npb €ianrpte,Contact
Mail ing Address:Tel
4s 0ettas Contact:
Mai I ing Address :Tel: ( )
CONSTRUCTI0N: (
Company:
Mail ing Address
Compl ete onl v if a I ication to construct or m odi fy tank )p
AlU Contact C&Sf
Tel (tc,n zer/as ( |
, State Contractor" License No.:
Construction Start Date
Attach a Plot P'lan Showing:(for new const ction an modification onl
_ Lea k Det ection Systern
Overfill Protection System
_ Location of all tanks and piping and
thei r secondary containment
Scal e
property Line -
North Arrow
-
Equipment Summary -
Nearest Intersection or Road
_ New and Existing Equipment
If thjs is an application to transfer ownership or operation of tank, complete fo1'lowing:
Previous Owner:
Add res s :
Cont act :
Previous 0perator: Contact:
Address:
Tel: ( )
Tel :()
Start Up Date:Date Installed:(for existing t anks )
na ure an t e icantA
**ur er e e ne
For ce se 0n v
P1 an Approved
Plan Disapproved _
Date o f Co ns t ruct i on Comp'l et ion
Date of Approval / Disapproval
Authorizing Agent Signature
IofZ
' i "- -f
-t 1Ft*nffffil*.,r*e-:?!{dit*qi:t-.*is;3ia{{1i:$,- rru**rStsnl||Il&lNi*ie;C*S...lE:ir!{ita:*l{..@.1r
---i-.-
, ) sAN LUl5 uulspo couN Iy ,.
.,/PLICATI0N FOR pERMIT T0 C0NSTRU" r.
, UNDERGROUND HAZARDOUS MATERIALS STORAGE TANK
M construct New Tank D Modify Existing Tank D rransferr of Ownership
M 0perate New Tank In or on the premises at Sn,r(h llt a L'6:EA
PART I
OWNER:
Company:
CONSTRUCTION:
Compa ny :
tf'le 0,rs Rtt"Contact:
, l'lai1ing Address:
OPERATOR:
Company:
l4ail ing Address:
Tel
Contact:
Tel: ( )( Compl ete onl v pl ication to construct or modify tank)a
afJ Con t act C&SfMailing Address:
Tel :(zr;9 7:?"/'{,3(/State Contractor License No.:, Construction Start Date:
Attach a plot plan Showing:
_ Location of all tatheir secondary co
_ Scal e
_ Property Line
__ Equipment Summary
(for new const tion and d ification onl
Lea k Det6ct jon Systern
_ Overff '11 protectfon System
_ North Arrow
_ Nearest Intersection or Road
_ New and Existing Equipment
operation of tank, complete following:
Contact:
If this is an appl ication to transfer ownership or
Previous Owner:
Add res s :
Previous 0perator:
Address:
Contact:
Start Up Date:
(for existing t
nks and piping and
nta f nment
Tel ()
Tel: (
an s
ure ana t e fcant
**24 Ho ur Emer n ele hone
Pl an Approved
Plan Disapproved _
Date of Construction Completion
or 0 ce se 0n v
Date of Approval /Disapproval
Aut ho r izi ng Agent S ignature
lof2
'lis'i:rd&"rir''-" f ia'i' '-s-s' .4ff!idiaa*iit6dtr,*a-!ti!:tlb.tt"#:l.. *,;J:it** :-l!a!ardE;.j-r.*^r€r.d*\.ft_..! :-
DIRECTIONS:
/--\, nDFL,,ni?f*LPffi 33ffi? f3'fJL,o,,,
UNDERGROUND HAZARDOUS I1ATERIALS STORAGE TANK
PART I I
Complete one form for each tank be.ing instal led/nrdi fied.
PROPOSED USE OF TANK:o/'/r7 ,e ,4r" /
MATERIAL(S) TO gT STORED IN TANK:r'Jr
VOLUMI OF TANK IN GALLONS:d U. L . NUMBIR at?
,MANUFACTURER OF TANK:
IF TANK USED PREVIOUSLY
Past Use of Tank:
t4aterial (s) Stored in Tank
TYPE OF CONTAINMENT:
Co nc rete
0ther
Fiberg'lass X Fibergiass Coated Steel
Thickness of Primary Containment
TY PE OF SECONDARY CONTAINMENT OR DRIP-PAN AS APPLIOABLE
Conc rete Fiberglass Coated Steel
fl Fibergl ass 0ther
Thick ness of secondary containrnent or Drip-pan as appl icabre
PIPING MATERIALS OF CONSTRUCTION:
D Steel E Fiberglass 0the r
Describe the leak detection system you plan to use for tank pressure lines
Describe the overfill protection system you plan to use Sp &x
What is the approximate depth of groundwater?
Basis of determination :
Attach a
tank and
proposed
a3lB1
c
p
ertification from the manufacturer, or his authorizediping materiats as.to the capabiliiy of i;e-;;;i ano ptored material s. (This appr i'es on'ry to lron-lrotor puer
h.*a^^1 **t 1
A\W \eAt /,^ u
| 3 5Ps'u 2or2
representative, of theiping material with the
trl
w:)/.{
Pro ducts ) .