HomeMy WebLinkAboutMinor Mod Permit App 6-15-2016UNDERGROUND STORAGE TANK
PERMIT APPLICATION IcArION
FIRE
ARTJM T
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
jPermit
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 -326 -3979 • Fax: 661 -852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY ❑ MUUlI-IUAI WN Ur rAi..1L1 T T Lai 11111NIUM 111vult 1%.rn i 1v11 %a1 . r,�,iL_i . .
STARTING DATE/ PROPOSED COMPLETION DATE
6 -13 -16 7 -13 -16
FACILITY NAME COSTCO #643 EXISTING FACILITY PERMIT #
FACILITY ADDRESS
4900 PANAMA LN CITY BAKERSFIELD ZIP CODE 93313
TYPE OF BUSINESS APN #
GASOLINE DISPENSING FACILITY
TANK OWNER RHONE #
COSTCO FUELS I 661 -837 -2026
I REPLACE 91 FLEX CONNECTOR IN DISPENSER #13/14 1
I WATER TO FACILITY PROVIDED BY
I DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
MAILING ADDRESS
6630 ROSEDALE HWY #B
I NAME OF TESTER FIDEL CARRILLO I IcC# 5257282
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 TES'T'ER I ICC#
FIDEL CARRILLO
5257282
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2686 (Rev 11/2015)