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. , , . <br /> � s <br /> 1=if���:�E t![��d�- � OFFICE OF ENI�I�lMENTAL HEAL�H • 59Q HAMILTqN STR�REDWQ��CITY,CA 94063 , <br /> (�4'15�363-a305 <br /> � €1hI C '�f I:':?�_/_.a��� . <br /> �;zft�E'T i� �.�d _.��..._,. AI� � T10N FOR PERMI�' T ABANDON <br /> ' G/� � � 3 �' ' �?�#' ��I i�Ii����{3��UND HAZARE30US 5T GE TANK <br /> 1. Facility Informafion y�.4 � �,f' ,1 <br /> Idprte of Faal�3y . �����a���� 7�ype u1 Business �� <br /> � r � <br /> � Slr[satlWtlress ` Ctly Ztp�odn 7etephone <br /> I � � � <br /> ' Conlrac[Aerwd Po tian with Compnny Telephonc <br /> � <br /> I � Ownecs Nnma(Corporasion.Agency,or InGFV�duak) <br /> SlEOat Address(If Ufi r t iha bave) GUy Z,�Code Telephnnc <br /> ��'rG � � 9 s.� �s-f�yr�-�as <br /> , 2. Contraetor Remo�ing 7anK _ ,`. <br /> ~ ompany Name Y -- --- - - - — y SlreeF Address - Cily � ~--^.Telophone <br /> ��� �� ��-Z6S�� <br /> 3. Soil Analysis Laboraiory <br /> Company Name Strcut Address Cfly �elephone <br /> �_J �,.���_ .�Tr 7��/�-� �� �`T� - <br /> �4. Hazarcfous Waste Nauler(if apprapriatel <br /> CompanyFiame Sl�celadcfress . C�ty 3cleppone <br /> .�: T . ' <br /> 5. Tartk ade�tification&Canstrncfion <br /> Tank K7�„..Q UL A ��/�a� Year Tank lnSiATled Vofume of Tank(GaSlonJ Cslhodia t'rolecllon <br /> � s— 600v � ❑ Na L7 Yes,Type <br /> Pdmary Cnnlainment � . <br /> f� Concrete L`i Sieel ❑ Fiberglass ❑ FibergEasslCoated Stael Q Other; <br /> 6. Cherrtica{Composltion.of Materials Currently ar Previously 5tnred Fn Tank � . <br /> cu�rentty previously Chemieal Dn No�tfsrt Commcrcla!Nam� �USa�drlioionaf papar Sor more room} <br /> slored 51GiB� CAS[��If koown) <br /> 0 41✓ Y ❑02 <br /> �01 0 02 � <br /> 061 �02 � <br /> 7. Piping • • <br /> � A. Abovegraund Piping: ❑ o� [7ouble-walled pipe � az Concrete•lined ireneh CI a3 Gra�ity ❑o� Pressure �os Suc#ion <br /> [(Check)apprapriate box(es)] ❑ os linEcnown 0 0� lVane <br /> i B. Undergro�nd Piping: C� n� Double-walfed pipe �oz Concre4e-lined trench C!oa Gravity � oa Pressure L"� 03 Suction <br /> � ((Checic)appropriate box(es)] O os Unknovrn ❑o� Na�e <br /> � 8. Dlspasitton at 7ank(Sy �� . <br /> Proposed Uispnsliion o[7ank�s� Reason for R�mnval <br /> � . � <br /> � 9. ,4p�iioant iniormation <br /> INa a o1 Applicant Signa �e oF 6 s Da10 <br /> � - ,.� ���,� ��� ('--iz�� � , <br />