HomeMy WebLinkAboutNEW CONSTRUCTIONUNDERGROUND STORAGE TANKS
NEW CONSTRUCTION/MODUCATION APPLICATION
KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT
2700 M STREET, SUITE 300
BAKERSFIELD, CA 93301
(661) 8628700 Fax (661) 862-8701
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TYPE OF ACTION ❑ 1. NEW SITE CONSTRUCTION ❑ 2. MODIFICATION 04 NEW TANK INSTALLATION AT EXISTING FACILITY A
(Check one item only)
I. FACILITY J SITE INFORMATION
FACILITY ID#
1
5
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1
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IN 1"
1
0
UST E NUMBER B
BUSINESS NAME (same as FACILITY NAME or DBA - Doing Business As) 3
BUSINESS SITE ADDRESS
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CITY e17 1 104 BUSINESS PHONE 102
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NEAREST CROSS STREET
401
11. CONTRACTOR INFORMATION
CONTRACTOR NAME
—11Z> D C
CONTRACTOR PHONE D
MAILING OR STREET ADDRESS
CITY F
I STATE G
ZIP CODE
CALIFORNIA CONTRATORS LICENSE NUMBER I
LICENSE TYPE
CERTIFIED INSTALLER x
ICC INSTALLER CERTIFICATION NUMBER L
IM SCOPE OF WORK
BRIEFLY DESCRIBE THE PROPOSED SCOPE OF WORK:
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IV. TANK LIST N
TANK NUMBER
PRODUCT(S)
CAPACITY
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0
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C L) 0-0
V. INTERGRITY TESTING/ENHANCED LEAK DETECTION
TESTING COMPANY
)D
PHONE P
TEST METHOD �j Q
VII. APPLICANT SIGNATURE
Certification - I certify that the information provided herein is true and accurate to the best of ray knowledge.
SIGNATURE OF PLICANT
DATE 4-14
PHON 425
NAME O1 F AtPPLIC T (print) 426
1
TITLE OF APPLICANT 427
A