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HUMBOLDT COUNTY UNDERGROUND STORAGE TANK PROGRAM page 1 of 2 <br /> SUPPLEMENTAL TANK CLOSURE PERMIT APPLICATION <br /> %CILITY NAME: 1�Ar., '� (�ei <br /> FACILITY ADDRESS: 15-714 j 1,,4,, n f01r) W In� A f �� <br /> JMBER TAN CLOS EMOVED: 2 NUMBER TANKS REMAINING: D <br /> l <br /> CONTRACTOR'S NAME: &,J 1 fPHONE: 727 6f I1)72-' <br /> 1FDICATE TYPE OF TANK CLOSURE YOU ARE APPLYING FOR: <br /> O PERMANENT CLOSURE OR <br /> ❑ REMOVAL TEMPORARY CLOSURE <br /> •CLOSURE IN-PLACE <br /> DTE: 'TANK' INCLUDES ALL ASSOCIATED PIPING WHICH CAN HOLD STANDING FLUID AND IS NOT PREVENTED FROM <br /> -.DLDING STANDING FLUID BY AN APPROVED DEVICE, FROM THE TIME OF INSTALLATION. <br /> ROVIDE THE FOLLOWING FOR EACH TANK: <br /> TANK CAPACITY AGE OF TANK TANK CONTENTS REMAINING PRODUCT DATE TANK <br /> (GALLONS) Y! EARS) (GALLONS) LAST OPERATED <br /> li q Ge xl.,c �2- l2.02 <br /> (yo 12-02- <br /> ALL TANK(S)CONTENTS MUST BE REMOVED AND DESTINATION DOCUMENTED PRIOR TO CLOSURE. <br /> HMAINING PRODUCT DESTINATION: 4Spyy1)( fnuuL inme,irat iInc I 56 ,5T Pp-6Aj,w .Clq <br /> NAME OF COMPANY HAULING REMAINING PRODUCT: _ ;Eco lt2q,_PrvirnQI <br /> —'A HAZARDOUS WASTE GENERATOR NUMBER FOR THIS FACILITY: CA-FOS pp zS*99 <br /> SOILNVATER SAMPLING FOR PRODUCT CONTAMINATION MUST BE DONE FOR PERMANENT TANK CLOSURE. <br /> AME OF LABORATORY TO BE USED FOR ANALYSIS: PHONE: <br /> NOTE: SUBMIT A COPY OF ANALYTICAL TEST RESULTS TO THE HUMBOLDT COUNTY DIVISION OF ENVIRONMENTAL HEALTH <br /> WITHIN 30 DAYS OF CLOSURE ACTIVITIES. <br />