HomeMy WebLinkAboutUST PERMIT APPLICATION 12-19-2013UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
Aft p 1501 Truxtun Avenue, 1st Floor
Bakersfield, CA 93301
EIS!' Phone: 661- 326 -3979 • Fax: 661- 852 -2171
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TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY ADDRESS laTy ` ZIP COD
TYPE OF BUSINESS APN #
TANK OWNER PHONE #
ADDRESS CITY ZIP CODE
CONTRACTOR,---,, CA LICENSE # ICC #
ADDRESS. `+�v .. � c� ZIP CODEn�
P ONE #' =BAKE FIELD:C3TY BIiSINESS.UCENSE # WORKMANS.COMP # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILr1 Y PROVIDED BY
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 0 NO ❑ YES ❑ NO
'THIS,SECTION IS FOR STORAGE TANK IDENTIFICATION
•TA*K #• VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING CO '\� n PHONE NUMBER � n `b rl
MAILING ADDRESS (:W5 0
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#
9
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
''•DA'tEAPPROVI D. APPROVE .B
/—� --13
FD2086 (Rev 08/09)