HomeMy WebLinkAboutUST PERMIT APPLICATION 7-15-15BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
T s..
Npn 2101 H Street
B•' $Bakersf ield, CA 93301
PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW FI�d Phone: 661 -326 -3979 •Fax: 661-852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD r" ARTAI
Page 1 of 1
Permit # ���� '
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY MODIFICATION OF FACILITY Q MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPLETION DATE
07/15/15
07/15/15
FACILITY NAME
EXISTING FACILITY PERMIT #
White Lane Chevron
FACILITY ADDRESS
CITY
Bakersfield
ZIP CODE
93304
2525 White Lane
TYPE OF BUSINESS
APN #
GDF
TANK OWNER
PHONE #
661 - 832 -9781
Proactive Properties, Inc. dba White Lane Chevron
ADDRESS
CITY
Bakersfield
ZIP CODE
93304
2525 White Lane
CONTRACTOR
Confidence UST Services Inc.
CA LICENSE #
8 04 9 0'4
ICC #
8177076 -U1
ADDRESS
16250 Meacham Road
CITY
Bakersfield
ZIP CODE'
93314
PHONE #
BAKERSFIELD CITY BUSINESS' LICENSE #
WORKMANS COMP #
1308371
INSURER
SCIF
661 - 631 -3870
32864
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Replace 87 shear valve in dispenser #5/6.
WATER TO FACILITY PROVIDED BY
I DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
�[:] YES n NO YES NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATIO
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
1 12000 x x
2 12000 x x
3 12000 x
Tank Testing Company
NAME OF TESTING COMPANY PHONE NUMBER
Confidence UST Services Inc. 661- 631 -3870
MAILING ADDRESS
16250 Meacham Road, Bakersfield, CA 93314
NAME OF TESTER ICC#
THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER
PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC#
Henry 177076 -�U 1
enry Meraz
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)