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CIt'y Of say tUIS OBISPO
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��. Fire Department • 748 Pismo St. • San Luis Obispo, Co.93401 •549-7380
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ADDRESS. = i I rl iquera HATE ; .;amiary 0, 1Q87
HAS PERMISSION TO MAINTAIN,
STORE, USE OR HANDLE MATERIALS, OR TO CONDUCT PROCESSES, OR TO INSTALL
EQUIPMENT AS DESCRIBED BELOW:
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Cif.y ordindn+ - jy). Tank to he filled with a mixture ;)f sand and rement.
ALL REQUIREMENTS SHALL BE PER THE UNIFORM FIRE CODE AND ITS STANDARD
THIS PERMIT IS NON TRANSFERABLE- IT SHALL BE POSTED IN PUBLIC VIEW AND
SHALL NOT BE REMOVED - BY ORDER OF THE FIRE CHIEF -
AMOUNT OF PERMIT: $
EXPIRATION DATE
BY;
I. D. N0.
1,iIler, HazaHmis t.lat(,ri.iI . Insnor.
Fire Department
u1zq�L1�W1 F`J6 ��ly l to 9 0�- i u n1 j Y� ti
to
to
to
E. Final Destination of Tank: hbAhJOM b jr-f PL{a-&It
Address Phone No.
[FIRE DEPARTMENT USE ONLY]
Describe Method for Retrieving Samples:
Samples Will be Analyzed For:
Laboratory That Will Perform Analysis:
Address: Phone:
THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF
MY KNOWLEDGE IS TRUE AND CORRECT.
Signature: � Petl-ylV\,- Title:_--JC ''cam Date:
RKM13-2
San Luis Obispo City FirE�Department Permit No. 1,33 %
748 Pismo Street Application Date
San Luis Obispo, CA 93401 No. of Tanks to be removed
APPLICATION FOR PERMIT FOR TEMPORARY OR PERMANENT
CLOSUREZREMOVAL OF UNDERGROUND
HAZARDOUS SUBSTANCES STORAGE FACILITY
Type of Application (Fill out One Application Per Facility)
[ ] Temporary Closure [ ] Permanent Closure [ ] Removal
A. Facility Name:_atAt.S J)Ry CLEf-n)ERS
Address: ')-14 1A,6Kyrg-4 Contact Person: inn
Phone: (days) (nights)
Owner: Phone:
Address: Zip
Operator: Phone:
Address: Zip:
B. Water to Facility Prov, .ded by: (—/Tq Dr- J . L •�
Depth to Groundwater:-O*',,11
C. Tank Removal Contractor:. 6i-5t(,1 enIS-T • CA License No.
Address: Pu Qzu i3 73 5- L.0 . Zip: 5'3 qo& Phone: S4r z 9S
Proposed Starting Date: ► 30 ? -I Proposed Completion Date: / - 3v ,Y7
Insurer:
D. Chemical Composition of Materials Stored:
Tank # Chemical (common name) Dates Stored
A-4 C LC n01 rJ e, �h U/ E NT-
Size Previously
Stored Chem.
to
to
to
E. Final Destination of Tank: )qB)gtj rj6-b Irrt PLA-LC
Address Phone No.
[FIRE DEPARTMENT USE ONLY]
Describe Method for Retrieving Samples:
Samples Will be Analyzed For:
Laboratory That Will Perform Analysis:
Address: Phone:
THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF
MY KNOWLEDGE .� IS TRUE
r, /AND CORRECT.
Signature: /I�PV� Title: �r/,%'��• Date: I-2,P-P7
RKM13-2