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page 2 of 2 <br /> HUMBOLDT COUNTY UNDERGROUND STORAGE TANK PROGRAM <br /> SUPPLEMENTAL TANK CLOSURE PERMIT APPLICATION <br /> OR ALL TYPES OF TANK CLOSURE, THE APPLICANT MUST PROVIDE A PLOT PLAN OF THE EXISTING FACILITY SHOWING PROPERTY <br /> OUNDARIES, LOCATION OF TANKS AND PIPING TO BE CLOSED OR REMOVED, UNDERGROUND UTILITIES,WELLS,AND ANY REMAINING <br /> TANKS. <br /> VECTION I-TANK REMOVAL <br /> WILL THE TANK(S)AND PIPING BE CLEANED ON SITE? W YES ❑NO <br /> YFS: NAME OF COMPANY CLEANING TANK AND PIPING: <br /> METHOD OF CLEANING TANK: <br /> IETHOD OF CLEANING PIPING: <br /> AME OF COMPANY HAULING RINSATE: <br /> COMPANY'S DHS HAZARDOUS WASTE HAULER'S LICENSE NO.: <br /> JANK/PIPING DESTINATION(FACILITY NAME AND ADDRESS): <br /> mg:NO: NAME OF COMPANY HAULING TANK AND PIPING: <br /> •OMPANY'S DNS HAZARDOUS WASTE HAULER'S LICENSE NO.: <br /> TREATMENT,STORAGE AND DISPOSAL FACILITY NAME AND ADDRESS: <br /> I _ <br /> WILL THE TANK(S)BE USED FOR SCRAP METAL? ❑ YES ❑ NO <br /> IF YES: SCRAP FACILITY NAME AND ADDRESS: <br /> fRE THE REMOVED TANK(S)PROPOSED FOR A SPECIFIC REUSE? ❑ YES Cl NO <br /> IF YES: NAME OF OWNER: <br /> IrCATION OF REUSE: <br /> ATURE OF REUSE: <br /> (CAL FIRE JURISDICTION APPROVAL IS REQUIRED PRIOR TO REUSING TANK FOR ABOVEGROUND STORAGE <br /> ECTION II-TANK CLOSURE 1N-PLACE <br /> LAME OF COMPANY CLEANING TANK: <br /> METHOD OF CLEANING TANK: <br /> IAME OF COMPANY HAULING RINSATE: <br /> OMPANY'S DHS HAZARDOUS WASTE HAULER'S LICENSE NUMBER: <br /> WHAT INERT SOLID WILL BE USED TO FILL THE CLEANED IN-PLACE TANK? <br /> IQUANTITY IN CUBIC YARDS:. <br /> SECTION III-TANK TEMPORARY CLOSURE <br /> RAME OF COMPANY CLEANING TANK: J5 ---- <br /> 1ETHOD OF CLEANING TANK: �f�f nI/. �t,luSe, T(�]11_ Pf����fL1 �fISP��R+-moi£R(2 ' <br /> OMPANY'S DHS HAZARDOUS WASTE HAULER'S LICENSE NUMBER: 3'L'33 (I LA 013 CA�L, ©(a^ <br /> PPLICANT S SIGNATURE: DATE: f 06 -ce <br />