HomeMy WebLinkAbout2525 Minor Mod forms 6-1-16_2-3UNDERGROUND STORAGE TANK
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PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW FIRE
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TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
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TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 -326 -3979 • Fax: 661- 852 -2171
Page 1 of 1
❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY
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❑
MODIFICATION OF FACILITY LI MINUK MUU11-1GA1lUN Uf- 1-AUIL11 Y
STARTING DATE/
CONTRACTOR
PROPOSED COMPLETION DATE
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EXISTING FACILITY PERMIT #
FACILITY ADDRESS
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CITY BUSINESS LICENSE #
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ZIP CODE
TYPE OF BUSINESS "
BRIEFLY DESCRIBE THE WORK TO BE DONE: A
APN #
TANK OWNER
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PHONE #
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ADDRESS
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PHONE #
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CITY BUSINESS LICENSE #
WORKMANS COMP '#
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE: A
i WATER TO FF YLITY PROVIDED BY
I DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
NAME OF TESTING COMPANY PHONE NUMBER
MAILING ADDRESS
NAME OF TE -TER 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 I ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED :. APPROVED BY,
FD2086 (Rev 08/09)