HomeMy WebLinkAboutUST-APPL 7/29/2015UNDERGROUND STORAGE TANK
BAKERSFIELD FIRE DEPARTMENT
Prevention
Services
PERMIT APPLICATION
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1501 Truxtun Avenue, 15t Floor
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILIM /NEW
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Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661- 852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
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:Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑
NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY)— ❑ MODIFICATION OF FACILITY ❑
STARTING
MINOR MODIFICATION OF FACILITY
DATE/
PROPOSED COMPLETION DATE
FACILITY NAME
EXI512NG FACUM PERMIT #
FACILITY ADDRESS
• ZIP CODE
TYPE OF BUSIN
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APN #
TANK OWNER
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PHONE # r
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WATER TO FACILITY 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?
O YES ❑. NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK, V VOLUME UNLEADED REGULAR PREMIUM DIESEL
OTHER
® CDC �,,--
to, 00 1
Tank Testing Company
NAME OF TESTMG COMP PHONE NUMBER
MAILING ADDRESS
o
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 PER]URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER PENALTY
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
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•... ,.
WATER TO FACILITY 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?
O YES ❑. NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK, V VOLUME UNLEADED REGULAR PREMIUM DIESEL
OTHER
® CDC �,,--
to, 00 1
Tank Testing Company
NAME OF TESTMG COMP PHONE NUMBER
MAILING ADDRESS
o
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 PER]URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER PENALTY
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
Dov r%oIn