HomeMy WebLinkAboutUST PERMIT APPLICATION 10-24-2014BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
2101 H Street
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PERMIT APPLICATION S Ia 1> Bakersfield, CA 93301
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY)/NEW FIRS I I, Phone: 661-326-3979 Fax: 661-852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD V
Page 1 of 1
IPermit #
I
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
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STARING DA;FEjt
PROPOSED CO_UPLETION DATE
FA,QfCTP NAME
EXISTING FACILITY PERMIT #
FACD.rrY ADDRESS
050,00'/
CrTm-
-/
ZIP CODE
TYPE. INESS
APU #
TAN ER
PHONE #
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ADDRESS
ZIL CODE
9"
CO OR
CA LICENSE #
ICC #
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ZIP ODE
PHONE #
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BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
I ER
77
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BYo000'-,)
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITEe--.)
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# OFTW
,XE INSTALLED
JARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO IV^
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES ❑ NO
THIS SECTION IS FOR STORAG, E TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY
PHONE NUMBER
MAILING ADDRESS
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#
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USEQt&Y
DATE APPROVED
7,6
APPJ VED)Y