HomeMy WebLinkAboutUST-APPL 8/11/2015;v
UNDERGROUND STORAGE TANK
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PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW FIRE
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD ARYA1
,Permit # 2.
TYPE OF APPLICATION: ❑ NEW TANK INSTALLINEW FACILITY [:] NFW TANK IN4ZrA1 I /EXISTT.NGFA_CII rrV
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1' Floor
Bakersfield, CA 93301
Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171
Page 1of1
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STARTING DATE/ ` S
PROPOSED COMP DATE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS A
CITY
ZIP CO
TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
ADDRESS �
J] I
CITY
ZIP COD
;�O(_/
CONTRACTOR
CA !M S #
iCC
ADDRESS
CITY
ZIP CO
PHONE # ( �
.. B—G; - .-
E
RSFIELD BUSINESS LICENSE #
`
C)OO
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
i2j.am
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TAnK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
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X
Tank Testing Company
NAME OF TESTING COMPANY
PHONE NUMBER t 4zy-
MAILING ADDRESS C-A T -6:-zSQS
NAME OF TESTER G
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 PER]URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ' k (�
71 rL�`J/ll
ICCdt
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
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APPROVED BY 4e _
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t -UZUnb (Rev us /o9)