HomeMy WebLinkAboutUST MOD. PERMIT APPLICATIONUNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
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D R S F I D
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield,, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page 1 of I
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 '„ EXISTINk FA CI PERMIT #
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FACILITY ADDRESS Ve, I CITY ZIP CODE (0
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TYPE OF BUSINESS
APN #
TANK OWNER PHONE Wa '0 15 _145 _7 q5 8p
ADDRESS CITY COD4 S 6 6 ID
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CONTRACTOR ('% # 1C #
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ADDRESS J CITY ZIP COUE .
1321 IP At tk-A Add,
PHONE # KERSFIELD CITY BUS NESS LICENSE # WO MANS COMP
17
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED
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 ❑ NO YES ❑ NO
THIS SECTION-zs FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY TPHONE 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 1C C#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
11130115-
FD2086 (Rev 08109)