HomeMy WebLinkAboutUST-APPL 1/13/2016i
Prevention
UNDERGROUND STORAGE TANK Services
k tion 5
is
2101 H Street
$ E x s g Bakersfield, CA 93301
PERMIT APPLICATION
Phone: 661 - 326 -3979. Fax: 661- 852 -2171
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY )JMOD -MINOR MODS -� page 1 of 1
Permit # J I
TYPE OF APPLICATION: ❑ NEW TANK INSTALLINEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLEVION DATE
FACILITY VAJE EXISTING FACILITY PERMIT #
t�
FACILITY CI Z
TYPE OF B SINESS APN #
TANK OWNER PHONE #
ADDRESS CITY ZIP CODE
CONTRACT .,,�, LI # ICC # ..-p
ADDRESS .� C r ZIP' qEj5:�,)C)
A .mot
PHONE #
taBAKERtSFIELID CITY B ESS LICENSE # WOR A C MP INSURER &C Ida 1�q
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
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
7649LIS SEMON IS FOR, SMIA E 7ANK EDZ- ` EFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL ' OTHER
Tank Testing Company
NAME OF E I PHONE NUMBER -7
MAILING ADDRESS
f
tp ?)v � ackle - � 14
NAME 9'rESTER/, A ICC# ra r --�"'7 �. e� 1
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.
.....� arnrr•s a ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
O OFFICIAL USE ONLY J
I
DATE APPROVED
FD2086 (Rev 08/09;