underground storage tank removal report ut-44 - Dtsc-ssfl.com

L ENVIRONMENTAL HEALTH DEPARTMEN T
APPLICATION FOR PERMIT TO ABANDON ATTACHMENT A
UNDERGROUND HAZARDOUS MATERIAL STORAGE TAN K
Joint Agency Application For Permit To Abandon Underground Hazardous Materials Storage Tank
TAii% LOCAlioN
Santa Susana F i eld Lati_ t D Woolsey Canyon Road - Burxo Mats
CUM1A, +toKe
O"ER
Plockwell Internation I.
MAILING ADOHESS ITtu+nher. StrM4 City and Tip Code9
6633 Canoca Ave . . Canoca Park, CA 91304
txONTACrrmtoN E
i)PERATgR
r (S1E€ 714-542 8
Plant Services/ M . G . Chi, : , _z
AEAik ,DtG ADDRESS dumb.'. Suait . City and Tip Codas
6 3 Cafoca Ave . Cancca Park CI: 91304
REMOVAL CONTRACtOR
g„t n
A u . Surat. Litt' and Zip Cpde i
730 Mountain View Avenue, Oxna rd CA 930375
WpRXMEN'S COMtpENSATtON INSURANCE COMPAN Y
Sentry - 574 Country Pd .Suite 1018", Ventura, CA 93003
x
AREA. 1
TANK
NO .
1
/' 3
/4
5
ATTACH A PLOT PLAN SHOWING :
Location of all tanks, piping and secondary
containment
Leak detection system
overfill protection syste m
Scale
North arrow
SIGNATURES OF APPLICANT OR REPRE SENTATIVE
PREVIOUS OWNER AND OPERATORS TANK(S )
cpNtACtr~rtoN E
S0 /64 -'5,r; 9
PHONE
805/654-177 7
FOR OFFICE USE ONLY APPLICATION : Q Approved ❑ Abandon in Place El-lemoval
t
❑
❑
❑
Fee See Conditions for Approval on Back of Form
Check No .
- - --- ~,
Receipt NO . ; J L_ C7eriiet3 I:ea5ott for [3etrial :
. . . . . . .
File No . kt e; _ i.
❑ Date "' By ~~fn a
DATE
RMA-7364 t2>P6 l
DATE
~rti' ^
OWNERIOPERATO R
COMPLETE THE FOLLOWING FOR EACH TANK TO BE ABANDONE D
SIZE CONSTRUCTION (Steel , Fiberglass, Etc . )
r _i14 L U_i
ry() . a a 2
SS E
5 te2l
C :4nrnlA C
Estimated Start Date mid-1111Y 10E,
#10' 1
:10 ^
`1v 3
#107
CONTENTS
PRESENT AND PREVIOUSLY
fuel O 1
fuel Cl i
fuel O i l
TCE wa ste
OiSTRIBUTtON: White- EH Cenary_CnntraetOt Pink-Applicant Goldenrod -Fire Dept .
DATE
2t~c)
~2 14
[11 Property lines
I] Nearest intersection or road
❑ Equipment summary
© Existing equipment and equipment to be
removed
HDMSe00024170