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HomeMy WebLinkAboutUST MOD. PERMIT APPLICATIONUNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD �Perrnit # j _j #,,'* j 2j0 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 # Hww�sj Kianill- I FACILITY ADDRESS Ve, I CITY ZIP CODE (0 • Vt.D ki, TYPE OF BUSINESS APN # TANK OWNER PHONE Wa '0 15 _145 _7 q5 8p ADDRESS CITY COD4 S 6 6 ID Mt V kL uk, A-ut- CONTRACTOR ('% # 1C # 6 42 3rg (.5 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: .e=A.valf 4-o +an 6-F ft *vw-A ctti d n 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)