HomeMy WebLinkAboutUST-APPL 8/14/2014UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILUFY)INEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
TYPE OF APPLICATION:
(CHECK ONE ONLY)
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 11� Floor
Bakersfield., CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page I of 1
0 NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
❑ MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAMT -�
EXISTING FACILITY PERMIT #
FACILITY ADDRESS ov
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ZIP COD
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TYPE OF BUSINESS
APN
TANK OWNER
PHONE #
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ADDRESS
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ZIP CODE
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CONTRALTO
CA LICENSE
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ZIP CODE
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BAKELZSFIELD CITY BUSINESS LICENSE #
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INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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?
0 YES ❑ NO
7HI-5,SECTION IS FOR STORAGE TANK IDENTIFICATION
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REGULAR
PREMIUM
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Tank Testing Company
NAME OF TESTING CO 19kAJff w
PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER
CC*
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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER R
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NC*
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
APPROVED BY
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