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%w 'We <br /> HUMBOLDT COUNTY UNDERGROUND STORAGE TANK PROGRAM page 2 of 2 <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 /> ECTION I-TANK REMOVAL <br /> WILL THE TANK(S)AND PIPING BE CLEANED ON SITE? ❑YES ❑NO <br /> =YES: NAME OF COMPANY CLEANING TANK AND PIPING: <br /> "AETHOD OF CLEANING TANK: <br /> METHOD OF CLEANING PIPING: <br /> TAME OF COMPANY HAULING RINSATE: <br /> r <br /> COMPANY'S OHS HAZARDOUS WASTE HAULER'S LICENSE NO.: <br /> ANKIPIPING DESTINATION(FACILITY NAME AND ADDRESS): <br /> r <br /> LFL—NO-1. NAME OF COMPANY HAULING TANK AND PIPING: <br /> :OMPANY'S DHS HAZARDOUS WASTE HAULER'S LICENSE NO.: <br /> I <br /> TREATMENT,STORAGE AND DISPOSAL FACILITY NAME AND ADDRESS: <br /> TALL THE TANK(S)BE USED FOR SCRAP METAL? O YES ❑ NO <br /> F YES: SCRAP FACILITY NAME AND ADDRESS: <br /> RE THE REMOVED TANK(S)PROPOSED FOR A SPECIFIC REUSE? ❑ YES ❑ NO <br /> 9F YES: NAME OF OWNER: <br /> 1 OCATION OF REUSE: <br /> IATURE OF REUSE: <br /> r <br /> LOCAL FIRE JURISDICTION APPROVAL IS REQUIRED PRIOR TO REUSING TANK FOR ABOVEGROUND STORAGE <br /> ;ECTION II-TANK CLOSURE IN-PLACE <br /> LAME OF COMPANY CLEANING TANK: <br /> YMETHOD OF CLEANING TANK: <br /> NAME OF COMPANY HAULING RINSATE: <br /> _:OMPANY'S OHS HAZARDOUS WASTE HAULER'S LICENSE NUMBER: <br /> WHAT INERT SOLID WILL BE USED TO FILL THE CLEANED IN-PLACE TANK? <br /> QUANTITY IN CUBIC YARDS: <br /> SECTION III-TANK TEMPORARY CLOSURE <br /> l <br /> ftr1AME OF COMPANY CLEANING TANK: <br /> METHOD OF CLEANING TANK: IPJ Rtt, RI-ose— Tpn t� 4UN:1 POT- <br /> ;OMPANY'S DHS HAZARDOUS WASTE HAULER'S LICENSE NUMBER: <br /> APPLICANTS SIGNATURE: e7 A• 4 (P g) DATE: I �j •_IQ� <br />