HomeMy WebLinkAboutMinor Mod Permit App 1-29-2016BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page I of 1
Permit #1&-I000 to
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
((-Wr-rlv r)KIP: r)r\11 V) r-1 Mr)nTPT(-ATT0N OF FA(-TI TTY 'Se MTNOP mr)nTFTrATTON OF FAMI T-ry
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME
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EXISTING FACILITY PERMIT #
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FACILITY ADDRESS
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CITY
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ZIP CODE
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TYPE OF BUSINESS
APN #
TANK OWNER
K,p rA C-CO A
PHONE #
3,f -C, ci
ADDRESS
5-72 k
CITY-
&-110
ZIP 1330 2 -
CONTRACTOR,
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CA LICENSE #
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ICC #
El" (-0434
ADDRESS
CITY
1' 6
ZIP CODE
a,330 &
PHONE #
W 57"? i"31f
BAKERSFIELD CITY BUSINESS LICENSE #
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WQRKMANS COMP #
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INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
0
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY
(>I -U'Allc�:%
PHONE NUMBER
I
MAILING ADDRESS r n
(4-- & 7el 4 3-5 0(4
NAME OF TESTER
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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
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
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APPROVED BY