HomeMy WebLinkAboutUST APP 12-19-13t1NMRGROUND STORAGE TANK
PERMIT
APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
FPer;it #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1st Floor
Bakersfield, CA 93301
)MRS Phone: 661 -326 -3979 • Fax: 661 - 852 -2171
ARf� f
Page 1 of
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACIu I Y
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS e`
CODE(; At
TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
ADDRESS `
d
ZIP CODE
CONTRALTO ,
CA LICENSE #
ICC #
ADDRESS
�+�fis �. t �
ZIP CODE
X330
I oNE
BAKE FfELO cznr BUSINESS : LICENSE #
.,.
woRKMANS . P # �,,`
INSURER .
BRIEFLY DESCRIBE THE WORK TO BE DONE:
V
WATER TO FACILITY PROVIDED BY
DT'PTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
Y
y# OE,TANKS 70 BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
p YES ❑ NO ❑ YES ❑ NO
11UMSECTION IS FOR STORAGE TANK IDENTIFICATION
VOLT NE UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING CO PHONE NUMBER
MAILING ADDRESS���
NAME OF TESTER - tom' J ' � 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*
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL U NLY
AP OVED
FD2086 (Rev 08/0