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HomeMy WebLinkAboutPERMIT.PLANS M-032-18 900 Moraine Ave, Fuel Tanks 2018-01-22Received Date Received By Town of Estes Park Application for Permit Number .M.7 le(.3 Pvliscella.neous erinit Application Expires. /:30ll Department of Building Safety 170 MacGregor Avenue P.O..Box .1200 Estes Park. CO 805/7 b Address: General Information & Inspection Line (970) 577-3731 * tiAX (970) 58641249* yt.ww.estesneLcont Per Contractor/Applicant: fensM__ Address- Stree() 0 Residential 0 Air Conditioning Installation eGas Line ( MO ft.) 0 Gas Log installation 0 New Furnace Installation 0 New Water Heater Installation 0 Temporary Structure Use Time Period 0 HAZARDS: Geo WildfircFIood on -Residential Valuation (Tota Cost of ate a I .crtiTy this application is true and correct and gree perfor the wo.rk described according to plans/specifications submitted, reviewed a.nd approved, and c.omply with Ilecal ordinances, state and .federa.1 laws as.well as building codes. certify that I have the property owner's authority and permission to apply for this permit.. Additionally, I UNDERSTAND THAT I A.M ' 0 WI N;ES OR EXPENSES INCURRED FOR PLAN REVIEAV, PERMITS, INSPECTIONS AND OTHER FEES ASSOCIATED Phone: _Tow Lkense 0 Siding 0 Windows 0 Fire/Water Damage 0 Drywall LJ Other re. Sta ( Cade) nattArc, StalT Comn ents: Census # Building Official Date VS. r Vg Print Name *** Office Use Only *** Date Per formation Permit Fee: Fee 1 County Tax: Total : ',\Servera',,eopiln de v uddin *Forms \.x3,ppl ic.41 ,Ovcr the Counter Page of Revised W20/2005 - SA JD ieri 'MI I National itr ark Village Gas Station 900 Moraine Avenue Eslies Park„ CO 80.517 Cr 0 V',1./INI. F S I" E. S FDA K R. GAPE E.) .J1sdN. 2 2 ?Dia e 80,0 Cif:II BAS 1E92 Big Thompson Avenue, Suite 100 Estes Park. Colorado 80517 OFL 78/5 ID (520 A P 1 ' 0 V t D : 12/21/17 1 FL 7 7 drld Pdf(d, ,OH;h," 1.116 ate iss Facility: 6520 - Fuel Station at National Park Village 900 Moraine Ave Estes Park, CO 80517 Larimer County Dear Owner/Operator and Installation Contractor: 1 7 The Division of Oil and Public Safety (OPS) has reviewed and approved the attached application .for the installation or upgrade of petroleum storage tank systems. Colorado Petroleum Storage -rank Regulations require that an inspection of the storage tank systems and facility be performed before construction is completed and before the systems are placed in or returned to service. Please contact the inspector identified below to arrange for an inspection, as well as the OPS office at 303-318-8023. Please call at least 72 hours before air is placed on underground piping or the construction is completed to allow enough time for an inspection to be scheduled. OPS Inspector: Orren Doss - 303-918-6307 Please use the enclosed registration 'form to properly register a new tank/facility or amend information concerning an upgraded existing facility. Thank you for your cooperation. NOTE: CO Storage Tank Regulations 7 C.C.R. 1101-14 (e)(1) requires that all UST secondary containment systems (tanks, piping, sumps, spill buckets, etc.) be tightness tested using an approved method at the time of installation, and again within thirty days of one year thereafter. All testing must be documented on the OPS Secondary Containment / Spill Container Testing form and submitted to OPS. This permit is autornatically revoked six months after the date of issue unless the Division of 011 and Public Safety grants an extension in writing. Also, six months or later after the date of issue, this permit may be modified by subsequent statutory or regulatory changes Effective January 1, 2009, all underground tanks and piping must be properly installed by OPS Certified UST' ,Installers, For information on how to become an OPS Certified UST Installer, visit the OPS Website at http://colorado,govicdleiops„ Colorado Department of Labor ai id Employment Phone: 303-318-8525 Divislon of Oil and Public Safety - Compliance Section Fax: 303-318-8518 633 1l7I1' Street, Suite 500 Elmal I: celle_odinspection@state.co.us Denver, CO 80202-3610 Web, www.colorado.gov/ops Underground Storage Tank System: L.,{J Installation or Cl Upgrade Apptication _____ A site plan (electronic or Mess than 1 rx17'") that includes the nameand address of facility, lot dimensions and distances from tanks to the nearest important building, roads, railroads, property lines, dikes or impoundment areas, existing tanks and dispensers must accompany this application. We encourage you to submit this application via email to c41e__otfl_inspe(cLronqtstate,c)p)..Ls, IIIIII1 Cie ne ram r 11 liliglik Plant fl FleetiCornrnescitil I El I3tilk 8, Rk:itall Motor iarelliry, El [41,111 MEill101i i'lleii lig Facility .Information Owner nformation Facility NOME: NAT l()NAL PARK VILLAGE GA.S b; TA ll. l0 ni C....gAiner Ni;iginie: PAPIN91 & HANKS 1...L.0 A d cl ressi 90(1 MORAINE AVENUE Ad d I-C. SS. : 903.1 ogrioRn :i..r,,Ar, ity/Slt:io/ZIP: tts lillitiii, PAriiiiT„ itio /iwr,1 7 N T., ,i,4 ( l 1 l iy unto)Naccii(i!: FRAN V< FLANKS CID Di e) (t. fN1(11(b FRANK HANKS. Erroll Address: riviroki,iiiiirgiiimpr9i yahrig.imiii, Ei Fool Address: trankandfrorm,e0,,a11,0,,,,(x.,rn Phone N u...i r n I) e r , (ty).3) 7 75 .5:,,:580 Phone Nurnliiiicr:.775-5680 Description of Work Type of Facility II(I) Rem I I I 1 Bull< Plant 1„..„i1orninetcliti1/Indust9 Airport i Fleidc!ral 1-1Si:sit lit,,, Govornrnent l .1 Erriergency Geneiriator I...10ther 'Tank Information I/ the tanks ore used for olternative/reriewoble firrels,, you must complete the con7Aotibility loan. 1. aril( Instollatirxi 1 ype TINE)* 1-11 x is t ing Fit'l New 11 E: x istii ng LI Nieiw I.....I fin ..ai ng Li i"(::,.s ri Null N/A .. (OPS Use) Tank ID Number O. Yes D No 0 N• tA j ioak Maniiilacturer EATUN mETAL EATON ME TAL 0' YeS I] No D N/A dank Modril TITAN "Ir PAN Yrii:,s11 No Ell N• /A ink Di.aryleter n in fl Y OS El No D N• /A Tank Lengthiiili 10 11. I n It in tt iri El yes 0 N• o 0 N/A Seriii:il Nurnlaroii L] Yes El N• o [11 N/A Tank Material Construction ,I K. 1 - ..5"Ick.me 0 S toe! 1 mik. „XI -r J 0 C '9±.,1,,,,...! .N-I -rank. [iil Yes Ej No El N/A Tank Wall Type twit -Dgi..itig,wm Dl," .. Double 'Mbll El Yes El No 11 N/A i Total Capacity 1 5.coci gal 15,iiiviio gal gal [ j Ye El No El N/A Cornpartrnentallized Tank.? FlYes 14 No 1,4Yes L....I No CiillYes r IN° Ei'l Yes ,1 No rl NIA .... (...:,orinipigitroent Srzes luireo 5.1i.r.1 f 'Yes 0 No fl N/A Produrk 01)919 o Id ed Tank.? TaYes No .1No Yes No 0 N/A Anclloi age Method )endmen YeS N El N/A 1911 Mantifiar turer OPW PliV El Yes LI No Fr j N/A P()cluciti lSectr)cril Conlparilaneirit) PRE J El Ye [T] No 0 N/A 1-TYes I,i)N I S Containnileint Size 42yEl U Yes No El N/A Spill Containrigint Type Bur...KEABOJC..KET [1 Yes El No Li N/A IOVI'I till Preiven0 on Met hod 9.; - in.ice El Yr', No N/A 'rue(' Overfill Prevention M...ani_gactuer .1,,Ii".k Corroslon liltrc)ter:t lion Inter-F(141a I Monitor -Mg (Tank)? :Kr 1,91iil.,,e. ed .:Ae ell 1 ..,e.i, lx•!il Y(Hi, OP W. ......... ilii - Jli,iiiiiiii! 5(V TAok l7l Ye !,.:', atiun rl No 1).1Yes t- (...I.i No El Yes El N• o El N/A Eil Yes L....1 No [.N/A El Yes El No ni N/A IntcasIatiia I Nilopitoring Type v IE. E D ER R 0 :)'-lj' N''') 'iv F.: En F R ROOT 4 Ej Yes lip No 0 N/A -li Aucornatic Tank. Gitroge (A,T(1)? i.......1No iii...IYes I..ii No l i.,.1 Ye st El Yes El No El N/A .71Yosi 1--1 N o A )() Manulactucer 0EE,[1:)1E9 0001- VE EDER 0110 I [l Yes Ej N• o [1 N• /A ATiG Model ILS 35(9 I 1S 1, !,.,:) Li Yes E] No El N/A vvith CS L D? II/I No I -Pees No i.........I Yes NI, ITi Yes E N• o El 'N/A Coropatible with the Product? 14 Yes t„„ii No i.,41 Ye s „ „ No fl Yes No El N/A Underground Tank Installation Information 0La1r4ril YI 1 MA Nth.' AC U RE R SPEC Top (..)1. 'Tianjin Deipt.h '1 111 Bedding Depth (12-inch mink-urnto unless hold-dcmn pad is used) 1,2 lin Burial Deiiipth 99111-1 C l) V e TY") e CONCREtE FAD -Thitaidiiess Will the excavation, (1)911'I LiILUOject 1:o trarriic? No Tarak MorfltonnF,Welk.,? / '7' N11Locatlon OPS Comments lYes 14 No Nurrther in 7875 111 652 F P "R, 0 "V JE 1.) 12/21117 Piping, Information if: the t.../i,th-og is 0,', Se d OE (14(21/10(./I/e/E000,VE(ble 10 (I yuo co! iste the itit,ItiptiinibIlity fore-o, Piping Irtstallatior) H lOtal 120 n 1'20 I t • [11 No Per.),:iiir or fit epi VINo 0,e0 No l......I No Li Y• es N• c) El N/A I V r1 vr [El Yes [1.111 No [11 N• /A Type 0.00;i0..oion00.00004,000, 1110p0r0g .Systerri Type Pip inty"-&M t 0'3211 Piping Wall Type El Yes.L.J No N/A ne-040.0,000.00000:0.00.0 01-2,2822...(3.282 [ S N 0 Ei N/A OJT . PILF".0.1c, 11,q...mug . 4,10,0tr: 1)crilb1,1 EVA( r„,j: YeSLi N c E] N/A, PIri)liitit, Ilylan 0.,ut act or er (we/ oriivy L-1 Yt:is 0 N• i, E1 N• /A Modell (Pisces, ked :11h e 1'3 CI 't F I... a XVVC.112„KS F3... E.IIEIN OR KIIIC 0 Yes Li Nt.:0 0 N/A I.....eak D0.0i,t ect or M ni.,if.:ict. ll ref' V BE ri P2. FIEII)(:)T \TEE:13FR ROOT 1,,:l Yes 0 Niii0 ri N/A I....eak Detectinir Type (Lir; Piping) 0::.-1.,.0/iiinn Ell Yes [1:11 No El NIA SIP PIniing Curmet:tor ( 1 a n k ) E.1.... r 4ex rt. . Pio, L] Y E.S L] NI. n N/A SIP Comaintnent VIanntackoret LI ii,,v o ENV FA Y OS [11 NO Il N• /A sT up 1 0 nt .:'1 in re ent M 0 cl el "ismii.i.0:iiii TIIIIIE2EIIILIILI Li Yes LI No Li i N/A S I IP tit)trosion Protect:n0n y FE, Yt..":"...; ' CI Yes El N• o IE) N/A Intersilual Monitoring (Pipe)? WIYes h: Ni.":0 fi0Yes 1-0 No 1-1Yes II No [71 Yes n No [] IN/A Interstitial Monitor:11-T type v EE DER Roo"r VI EDEIIII< ROOT [1 Yes 0 No 0 N/A Ii1lt age itt-1 Vapor- 11ecovery? IrlYes I..„.I No I,,IYes 1..„„I No 1 IYes I,/.1No El Yes 1] No [-I N/A 1t0aite if 'I Pi pi rig Size s [1] Y• es LiNo LI N• /A Dispenser" Information If the di.v. t ser s 70 USed for aiterpotive/renelmcble Plets,. you P-Rist complete the cpropolibility,form, N e spe roSer It11alle ? 17, Yes lI No feilYes No 1 IT Ye s I-1Np El Yes n No 0 NiA DR; pe n ser M n IT f a ct 0.1 r e r Gri. BA R CO GIL l'II A R 9 1 L D Yes 171, No ri N/A Dispenser 11.011odie I ispectRis ii/90--i ENepRiE mciii 11:11 Yes 0 No LI N/A NiiiIEP Certificate cit Conlor Ma n co Nurrtaer r 1.]i Yes Ell No [ N/A Nurtiber of Dispensers 3 in 1....,.„1No 0 Ye S 0 No 0 N/A 1L.1 Yes. 1...Incler Dispenser Containtrent (1,..,1DC)? 1,......1No 1,(.:1 Yes I.......0 No I......I Yes 1.:.1 Ye S 1""..1 No r_j N/A (..11)(..,: M an in f a c t trrer F3 RAVE) BRAVO Ll Y e LI, ri No 0 N• /A Ul)C. Model E,I,,B fi1C/00 8 P.-EI 'I 90() , 1:1 Y 05 [I No 1.171 N/A LT_I Yes n No 0 N/A Blender Dispensit?0rs? 1,./.1Yf'S 1 l\i0. VI YO 5 N0 1 I YC.:!S 71 No 0 Yes Ll NO Li N/A In M et 0 rTS per Dispenser , DOC. Piping Lennector Dispenser UDC Corrosion Protection Cornix,iny Nar»e: Address: E.10-00,i01 Adress, trib mp ny Na roes Address: Email Address: instalir?r Certitication NuriMer: (P)r:op/my Name, Address: FLEX HOE VALVE IN UDC IF LE X1i/[VAiVE E] YO 1 No 111 N• /A IN UDC ri YE'S [1] No N/A Project Contractor inforrnation ELLion3011133 SERVICE S. INC. (1 ntoot Narne: 3,7E4 DIRE 'CA 3102 1Z.1P II" I) ON 0 Niorri he i", ABR RI EL I_ [OTT EID K. (O Fuel System Installer Information EL LILIETT PARTS & SERVICES. INC,. C011 tI 3 EL N a rine : 0 GAB R IF li CI I icyrr 3'764 E V. I R E KA 'VVAY /15 C II ty/1Stai.e/Z111": il FR E DER IC k , CO 80518 .yit.,,,,,-,4>eps!uo.co.n. Phorbe Number: 3.23-22I0-(3636 cotinoA Calibration Company Information i<urtAt rOOIPMENT CO, (or -iitact Narne 1007ie G01 nisAiRo sTRE Cilly/Sta1e/Z1V1: MitIfLEL 73RNEL AII r)rNvr R., CO 80223 Czilibration Certikation NurnIter: Phone Nitroner: :00:1.0-m-32011 Owner Authorization RANK HANKS 1'1845E17 W El C.', Ei rICI."2F) P'S9rlllliV0 Narne: Date:. For OPS Use Only C:Iiieck Name: Effloi Ist4,0S -7-Ch , k it: TH557 i k:(.., I CpeCk Amount: $150 Check Date: 1 11,07 Fi[)# j 652.00 OID rtt: Date 'R0E630E1 ` 1.....!..0._1Reviewed By : rtm1 Decison Date: 12(21,1 i DCiSc)n Mad : I] Approved ri Denied __ Deficiency [I Modified .._ Additional Date Received: I 1 Revieweitl By: r Additional .Decision Date: 1- Additional Decision Made.: - Approviecl Denied ---1 Deficiency -i Modifiec..1 i _... Buried Piping Test Test Date J ()PP fn5pec tor Results Test Method Test Methoti Secondary .Containment Test TeS Date OPS. Onspec[Or Results CM," 787 1141) 6520 A P P IR, 0 'V E D 12/21/17 Colorado Department of Labor and Employment Division of il and Public Safety-[unmphanceJacdom 633`17pStr 00 Denver, CO 80202'3618 Phone: 303'318-8525 Fax: 303-318-8518 Email: cd|e_oil imspecdmn@state.co.us Web: www.co�orado.gov/o�ps Notice of Intent to Permanently Close Storage Tanks or Change -Service (Revised 11/2013) Cornpilete this notice and submit it such that kwill be received at least 10 days but no more than 30 days before closure activities begin. Please contact uSat,3O3-31&-853lo,3O3318`8S07ifyouhaveanyquesdmos. Check one of t he fol1lowing op�ti�ons. Ivipermanen,Uosure-hyRemova oPemnanenr�usue-|nP��e o �han�e�n�cr�cenoNon-regulatedProduu ���� ____- �_� __.... Site AssessmemtInformation You are required to conduct a, site assessment in conjunction with perl"nanent closure or change -in-service and submit eitherthe o�tn assessment completed with laboratory analytical data and a Mgore depicting all fuel system components and sample _hz_cahonsorn e d which she mobe completed. ___ _U � S�eassessmenchas been performed, _o Site assessment wwooeperformed. Fire Department Notification Information Contact your locail lire department prior to closure or change -in-service to ensure you comply with their requirements. ocal Fire Department: E Local fire department has been notified. Facility Information ryNanne: Faci|icyID#: NATIONAL PARK VILLAGE GAS STAT�ON L Local fire department will be notified, Facility Address: 900 MORAINE AVENUE Name: Company Name'. EsTES PARK, CO 80517 Owner Information* FRANK HANKS Qwner|D#: Address: OXFORD ROAD [ Phone Number: _ Emai|Address: omoIVIowr.couosw Name: GABRIEL ELLIOTT Contractor Information* Company N ame� Address: ELLIOTT PARTS & SERVICES, INC. 76wEUREKA WAY ms City/State/ZIP: FnsosnIC^oomm1s Phone Number: (�720) 638-8876 Email Address: gabe@ePSfUeI,C0M Date tanks were emptied to less than I inch: ate oftankemm�kc|mureorchange-in-service #o[USTs: TaimkUmforrnation Install Date (year) Capacity (gallons), ox ofASTs x Product Stored in Tank Proposed Product*** 1978 10.000 UL � o 197 O O O o i O *Please provide information forthepe,sonvvhoshnuh1eceherheOPSAcknuw|edQ*memtLetter, **If this date changes, please notify the DMsion of Oil and Public Safety immecliate�. **^[ompoenethis item for chan8e'in'serviceonly. 10,000 UIL Colorado Divis,ion of Oil and Public Safety w2�����}o/a1�`,F����� COLORADO Department of Labor and Employment Division of Oil ,and Public Safety 633. 17' Street, Suite 50(.) Denver, CO 802.Q:12.-3610 303-.318-8525 I viviv,,,coturado,gov /ups LIN I The Division has received your notice of intent o close or remov' lundergroundiabovegroun storage tanks at: FACILITY ID#: 6520 SITE NAME: Fuel Station at National Park Village SITE ADDRESS: 900 Moraine Ave SITE CITY: Estes Park I No. of tanks, size, or contents of tanks not include( I Actual location of tanks not clearly stated I No record has been found for this facility. We have assigned this site the above Facility ID #. If there are any other underground storage tanks at this site, you MUST register them on the enclosed form. No mention of a "site assessment" was made. (You must assess the tank site for possible contamination at the time of closure)...see "Note" below and appropriate attachments. I You must also notify the Fire department having jurisdiction over the facility, and make sure that no building permit is required by zoning commission. X No problems with the notice. •Call Michelle Howard at 303-318-8507, or the Technical Assistance line at 303-318-8547 48 hours prior to tank closure to confirm the date and time of closure activities. .Tanks must be cleaned and inerted prior to removal activities. •If laboratory data indicates a detection of regulated substance in the environment a confirmed release must be reported to OPS at (303) 318-8547 within 24-hours of receiving analytical data. If there is a confirmed release for the closure a Site Characterization Report (SCR) is due within 180-days of the sampling date and a Tank Closure Report is not required. All data from closure activities is required to be in the SCR. 'Retain all Annual Compliance Package documents up to the date of closure. o ,ot„, Colorado Department of Labor and Employment Phone: 303-318-8547 — ---- ,r,,,7 Divislon of Oil and Public Safety - Compliance Section Fax 303-318-8546 • • 633 179' Street, Suite 500 Email: cdle_oil _inspectlon@state.co,us • /(7b . Denver, CO 80202-3610 Web: www.colorado.gov/cdle/petroleum ' 1 ' ' T 1 II Facility information Facility Name: Facility Address: NATIONAL PARK VILLAGE GAS STATION 900IMORAINE AVENUE City: f _ Facility iD #: 6520 I ZIP: ....,______ Owner/Operator Information Tank Removal Contractor Information Name: Company Name: FRANK HANKS PAIPINI & HANKS LLC Name: COITIparly Name: GABRIEL ELLIOTT ELLIOTT PARTS & SERVICE'S, INC, Address: 9931 OXFORD ROAD Address: 3764 EUREKA WAY #5 City/State/ZIP: LONGMONT, CO 80504 City/State/ZIP: FREDEIRICK, CO 80516 Phone Number: (303) 775-5680 Phone Number: (720) 638-8876 Email Address: frankandjoannpyahoo.com Email Address: ' gabe©epsfuel.cong Tank information OPS Tank ID # UST or AST? Capacity (gallons) 10,000 Product Stored in Tank UL Closure Date Closure Type Closure Assessment? Suspected Release? 10000 t)i Closure by Removal Date OPS notified of intent to close tanks: Inspection Item OPS Closure Acknowledgement #: Contractor Verified? ACK inspector Verified? N/A 1. Product from piping drained into tank or other container. . Piping disconnected from tank and removed (or cleaned out, plugged and dispensers removed for ASTs). 3. All liquid and residue removed from tank using explosion -proof pumps or hand pumps. 4. All pump motors and suction hoses bonded to tank or otherwise grounded.LXJ 5. Fill pipes, gauge pipes, vapor recovery connections, submersible pumps and other fixtures removed. 6. Vent lines left connected until tanks purged. ri 7. Tank openings temporarily plugged so vapors exit through vent, 8. Tank atmosphere reduced to <10% of the lower explosive limit (0._EL) or <5% oxygen before removal. 9. Tank removed from excavation after purging/inerting, placed on level ground and blocked or secured. 10. Tank cleaned before being removed from site. " 1. Tank labeled appropriately before being removed from site (per Vocal authority). __ ___...._ 12. Tank vent hole (1/8" in uppermost part of tank) installed prior to removing the tank from the site. Li ___... 13. Site security is provided while excavation is open. — Colorado Division of Oil and Public Safety Tank Closure inspection Form Page 1 Closure in Place Date OPS notified of �ntent to close tanks: | l Inspection Item OPS Ciosure AcknACK Oom-�mcr Unmo�� ----' -_ Verified? Verified? - - - - - l Pnoduokorn piping drained into tank or other container. � 2� Piping disconnected homtankaindremoved (or cleaned out, plugged and dispensers removed for A,ST$. 3. All |muidaod�sidveremoved from tank using |os�n f hand 4. All pump�noto,s and suction hoses bonded ro tank or othervisegrounded. 5, Fill pipes, gauge pipes, vapor recovery connections, submersible purrips and other fixture's removed. 6, Vent lines left connected until tanks purged. T Tank openings temporarily plugged so vapors exit through vent. 8, Tank awrospMmmreduced to<11 0%ofthe lower explosive limit <LEUor<5%oxygen before closure. 9, Tank properly cleaned to remove all sludge and resiclue. 0. Soilid inert material (sand, cyclone boiler slag, peagravel, etc.) introduced and UST filled,, 11. Vent line disconnected orremoved. 12, Site security isprovided while excavation is ASTsinp|ace). :)[ en (or safeguarded against trespassing for Method ofVapor Freeing Tank Method Calibrate combustible gas indicator and/or oxygen irneter prior to use. Contractor Verified? Drop mie.removed prior tochecking atmosphere. Displacement of vapors by Eductoir or Diffused Air Blower _ �rt Gas using Dry Ice or Liquid CO-,� Inert Gas using CON Readings of <1 011/6 of the LEL or <5,Xo oxygen obtained before removing tank. Tank atmosphere mon�ored for flammable or combustible vapor levels prior to and during cleaning and cutting. Tank space monitored at bottorri, middle and upper portion, Inspector Verified? NIA SiteK8ap Show all tanks, p�iping,and dispensers, Identify the tanks being closed under this A[Kand the tanks remaining in service. Notes/Comments: UPS Inspector Information VPSArnpec�.�Name: ___ Inspector Signature: Inspection Date: Colorado Division of Oil and Public Safety Inspector Phone #: Tank Closure Inspection Form Page 2 Received Date Received By Town of Estes Pik Application Permit Number 11'I- µ , DePa�entofBalldin for Miscellaneous Per General Information of i Inspection 170 MacGregor Avenue P.O. Box 1200 • mjt Application lrxpites ' Hon Line (970) 577 373Y *FAX (970) 586-024F9 Park, CO 80517 Job Address. f A Owner Name: Address: 1 Contractor/Applicant: 0 Residential Opr Conditioning Installation Gas Line ( IRO ft.) 0 Gas Log Installation o New Furnace Installation ❑ New Water Heater Installation ❑ Temporary Structure Use Time Period ❑ HAZARDS: Geo Wildfire Flood Description of Work: Valuation (Total Cost of Material & Labor): 5 1301 t3-1,c31) 1 certify this application is true and correct and local ify this appl state and federal laws as andwell agrees to building �yqwork described according to plans/specifications submi UNDERSTAND THAT I AM w t certify that i have the property owner's authorityand 'dewed and approved, and comply with FEES ASS OR EXPENSES INCURRED FOR permission to apply for this permit_ Additionally, [ ASSOCIATED PLAN REVIEW, PERMITS, INSPECTIONS AND OTHER Phone: P1E110'00'7' CLOSED Permit Expo Staff Comments: the Counter Page 1 of 1 Permit Fee: County Tax: Permit Information Revised 10/20/2005 - SA