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page 1 of 2 <br /> HUMBOLDT COUNTY UNDERGROUND STORAGE TANK PROGRAM <br /> SUPPLEMENTAL TANK CLOSURE PERMIT APPLICATION <br /> tCILITY NAME: r# r z#i c �e'I f <br /> FACILITY ADDRESS: 51"1 (]A a'- <br /> tMBER TANCLOS EMOVED: � NUMBER TANKS REMAINING: <br /> C <br /> CONTRACTOR'S NAME: MOSS' �J)U I I O F1(pPiJ(�fia1� PHONE: <br /> INDICATE TYPE OF TANK CLOSURE YOU ARE APPLYING FOR: <br /> ❑ PERMANENT CLOSURE OR TEMPORARY CLOSURE <br /> ❑ REMOVAL <br /> ❑CLOSURE IN-PLACE <br /> UTE: "TANK" INCLUDES ALL ASSOCIATED PIPING WHICH CAN HOLD STANDING FLUID AND IS NOT PREVENTED FROM <br /> LDING STANDING FLUID BY AN APPROVED DEVICE, FROM THE TIME OF INSTALLATION. <br /> tOViDE THE FOLLOWING FOR EACH TANK: <br /> TANK CAPACITY AGE OF TANK TANK CONTENTS REMAINING PRODUCT DATE TANK <br /> (GALLONS} (YEARS) (GALLONS) LAST OPERATED <br /> q C,atp�, ".c 2_ (2-02 <br /> Dtt � 2-OZ <br /> ALL TANK(S)CONTENTS MUST BE REMOVED AND DESTINATION DOCUMENTED PRIOR TO CLOSURE_ <br /> LINING PRODUCT DESTINATION: - Im I L jrn�v,�.cr>,Inr r>,r t 1 1 � � S }�,�C-q .� <br /> ME OF COMPANY HAULING REMAINING PRODUCT: i0lrcoLo}, , (,Okivi <br /> 'A HAZARDOUS WASTE GENERATOR NUMBER FOR THIS FACILITY: -�- )-599 <br /> 59 r <br /> 1 <br /> SOILIWATER SAMPLING FOR PRODUCT CONTAMINATION MUST BE DONE FOR PERMANENT TANK CLOSURE. <br /> I <br /> ME 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 />